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Arizona Health Care Cost Containment System Appropriation Status Report Fiscal Year 2013 through December 31, 2012

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              Janice K. Brewer, Governor
Thomas J. Betlach, Director
801 East Jefferson, Phoenix, AZ 85034
PO Box 25520, Phoenix, AZ 85002
Phone: 602-417-4000
www.azahcccs.gov
Our first care is your health care
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
January 25, 2013
The Honorable Andy Biggs, President
Arizona State Senate
1700 West Washington
Phoenix, AZ 85007
The Honorable Andy Tobin, Speaker
Arizona House of Representatives
1700 West Washington
Phoenix, AZ 85007
SUBJECT: FY 2013 Appropriation Status Report for the Period Ended December 31,
2012
Dear President Biggs and Speaker Tobin:
Pursuant to A.R.S. §’s 36-2920 and 36-2994, enclosed is the Arizona Health Care Cost
Containment System’s (AHCCCS) Appropriation Status Report (ASR) for the period ended
December 31, 2012.
Status Summary - As part of the FY 2014 budget request submitted to the Governor’s Office of
Strategic Planning and Budgeting, a FY 2013 rebase was prepared. This rebase indicates that the
current appropriations are expected to be sufficient to cover projected agency expenditures with
a small estimated surplus. For purposes of this report, projected annual expenditures remain
equal to the appropriations. The projected annual expenditures are subject to several factors
including: caseload trends, expenditure trends, potential Agency audit liabilities, information
system issues, CMS decisions, and tobacco funding. AHCCCS will continue to monitor these
factors and will provide a projected annual appropriation estimate when more data is available.
Expenditure flows for the first six months of FY 2013 have been impacted by changes to the
AHCCCS claims and encounter systems to become compliant with the HIPAA 5010
requirements (5010 refers to an electronic file format mandated by HIPAA for both claims and
encounter submissions). These system conversions, and the corresponding changes made by
AHCCCS health plans and program contractors, has resulted in abnormally low and erratic Fee-for-
Service and Reinsurance expenditures and has also impacted Prescription Drug Rebate
encounters and invoicing. AHCCCS expects the final expenditures/collections for the year to
return to normalized levels. However, the year-to-date expenditure flows remain unstable and
caution should be exercised when analyzing the year-to-date data.
The Honorable Andy Biggs
The Honorable Andy Tobin
January 25, 2013
Page 2
Enrollment Update – December 2012 enrollment, excluding Healthcare Group and certain
Medicare Cost Sharing members, is 1,266,727 members, a 4,088 member decrease over the prior
month. Enrollment for January 2013 increased to 1,268,918 members, a 2,191 member increase.
Childless Adult Enrollment Freeze Impacts
The Phase-Out Plan for Childless Adults was approved by CMS on July 1, 2011 with an
effective date of July 8, 2011. The January 1, 2013 Childless Adults enrollment is 86,719, which
represents a decline of 137,773 members from the 224,492 members enrolled as of June 1, 2011.
This overall decrease includes a transfer of 13,289 childless adults who were seriously mentally
ill, or age 65 and over, or had Medicare or HIV/AIDS to the Supplemental Security Income
Medical Assistance Only program as required by the Phase-Out Plan.
Additional information reported to CMS regarding the impact of the above changes is located on
the AHCCCS website at:
http://www.azahcccs.gov/reporting/Downloads/1115waiver/CMS_PhaseOutActivityMonthlyRep
ort.pdf
KidsCare Enrollment Freeze and KidsCare II Impacts
KidsCare and KidsCare II enrollment – The January 1, 2013 KidsCare enrollment is 34,125,
which is comprised of 8,281 members in the state plan program and 25,844 members in the
KidsCare II waiver program. Enrollment for the KidsCare state plan program, which has been
frozen since January 1, 2010 due to budget deficits, declined by 98 members from the prior
month and 37,539 members from the 45,820 members enrolled as of January 1, 2010.
Tobacco Funds Revenue Update – Tobacco tax collections through December 2012 are $2.0
million less than the AHCCCS monthly projected flows. AHCCCS will continue to monitor the
tobacco funds revenue collections to determine any impact on the FY 2013 appropriations.
If you have any questions about this report, please do not hesitate to call me at (602) 417-4111 or
Jim Cockerham at (602) 417-4059.
Sincerely,
Thomas J. Betlach
Director
The Honorable Andy Biggs
The Honorable Andy Tobin
January 25, 2013
Page 3
Enclosure
cc: The Honorable Janice K. Brewer, Governor
The Honorable Don Shooter, Chairman, Senate Appropriations Committee
The Honorable John Kavanagh, Chairman, House Appropriations Committee
The Honorable Nancy Barto, Chairman, Senate Health and Human Services Committee
The Honorable Heather Carter, Chairman, House Health and Human Services Committee
John Arnold, Director, Governor’s Office of Strategic Planning and Budgeting
Richard Stavneak, Director, Joint Legislative Budget Committee
Arizona Health Care Cost Containment System
Appropriation Status Report (ASR)
Fiscal Year 2013
Through December 31, 2012
Prepared by: Division of Business and Finance
Arizona Health Care Cost Containment System
Appropriation Status Report
Table of Contents
• APPROPRIATED SOURCES AND USES OF FUNDS Page
Summary of Appropriated Expenditures for SFY 2013 2
Appropriated Expenditures by Funding Source 3
Appropriated Revenue Received Detail Schedule 4
• FOOTNOTES 6
• CASELOAD AND EXPENDITURES BY RATE CODE 9
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
APPROPRIATION STATUS REPORT
APPROPRIATED SOURCES AND USES OF FUNDS
(A) (B) (A) - (B)
EXPENDITURE PROJECTED
ANNUAL PLAN EXPENDITURES VARIANCE ANNUAL ANNUALIZED
APPROPRIATION YTD YTD YTD EXPENDITURES VARIANCE
APPROPRIATIONS:
ADMINISTRATION
AHCCCS Operating Lump Sum $ 77,682,100 $ 38,689,900 $ 34,368,387 $ 4,321,513 $ 77,682,100 $ -
AHCCCS Prop 204 Administration 8,934,500 3,906,600 3,926,166 (19,566) 8,934,500 -
DES Eligibility 54,247,600 26,960,400 24,134,779 2,825,621 54,247,600 -
DES Prop 204 Eligibility 37,945,700 18,917,200 4,830,045 14,087,155 37,945,700 -
TOTAL ADMINISTRATION 178,809,900 88,474,100 67,259,376 21,214,724 178,809,900 -
Traditional Medicaid Services 3,420,887,100 1,622,435,000 1,592,239,910 30,195,090 3,420,887,100 -
Proposition 204 Services 1,166,614,700 584,215,800 571,917,340 12,298,460 1,166,614,700 -
Children's Rehabilitative Services 127,941,500 65,217,800 59,903,975 5,313,825 127,941,500 -
KidsCare Services 21,622,300 12,248,100 10,126,940 2,121,160 21,622,300 -
ALTCS Services 1,177,910,000 548,936,600 548,522,259 414,341 1,177,910,000 -
Disproportionate Share Payments 13,487,100 - - - 13,487,100 -
DSH Voluntary 77,248,900 44,086,900 44,086,780 120 77,248,900 -
Rural Hospitals 13,858,100 - - - 13,858,100 -
Graduate Medical Education 169,735,300 164,853,700 164,853,796 (96) 169,735,300 -
TOTAL PROGRAMMATIC 6,189,305,000 3,041,993,900 2,991,651,001 50,342,899 6,189,305,000 -
TOTAL EXPENDITURES $ 6,368,114,900 $ 3,130,468,000 $ 3,058,910,377 $ 71,557,623 $ 6,368,114,900 $ -
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2013 APPROPRIATION STATUS REPORT
For the Period Ending December 31, 2012
SUMMARY OF APPROPRIATED EXPENDITURES
2
(A) (B) (A) - (B)
EXPENDITURE PROJECTED
ANNUAL PLAN EXPENDITURES VARIANCE ANNUAL ANNUALIZED
APPROPRIATION YTD YTD YTD EXPENDITURES VARIANCE
STATE - GENERAL FUND
Administrative Expenditures $ 52,247,100 $ 26,210,700 $ 24,923,662 1 ,287,038 $ 52,247,100 $ -
Proposition 204 - Administrative Expenditures 21,081,800 10,149,700 3,609,157 6,540,543 21,081,800 -
Programmatic Expenditures
Traditional Medicaid Services 914,805,100 424,468,500 411,471,906 1 2,996,594 914,805,100 -
Proposition 204 Services 191,023,200 145,647,700 136,111,314 9 ,536,386 191,023,200 -
Children's Rehabilitative Services 43,285,600 21,791,100 20,035,631 1,755,469 43,285,600 -
KidsCare Services 5,132,600 2,875,400 2,223,217 652,183 5,132,600 -
ALTCS Services 162,594,300 77,207,900 77,346,707 ( 138,807) 162,594,300 -
DSH and Rural Hospitals 7,942,600 - - - 7,942,600 -
TOTAL GF EXPENDITURES 1,398,112,300 708,351,000 675,721,595 32,629,405 1,398,112,300 -
FEDERAL
Administrative Expenditures 77,259,800 38,238,000 32,974,224 5 ,263,777 77,259,800 -
Proposition 204 - Administrative Expenditures 22,577,300 11,063,700 4,341,778 6,721,922 22,577,300 -
Programmatic Expenditures
Traditional Medicaid Services 2,201,471,200 1,034,496,000 1,028,003,320 6 ,492,680 2,201,471,200 -
Proposition 204 Services 816,000,700 408,022,800 406,010,626 2 ,012,174 816,000,700 -
Children's Rehabilitative Services 84,655,900 43,426,700 39,868,344 3,558,356 84,655,900 -
KidsCare Services 14,531,200 8,255,900 7,180,476 1,075,424 14,531,200 -
ALTCS Services 752,042,100 346,723,300 343,087,813 3 ,635,487 752,042,100 -
DSH and Rural Hospitals 19,402,600 - - - 19,402,600 -
DSH Voluntary 51,214,600 29,259,400 2 9,259,363 37 51,214,600 -
Graduate Medical Education 114,942,700 112,559,100 112,768,902 (209,802) 114,942,700 -
TOTAL FEDERAL EXPENDITURES 4,154,098,100 2,032,044,900 2,003,494,845 2 8,550,055 4,154,098,100 -
COUNTY
Administrative Expenditures Proposition 204 - BNCF 3,221,100 1,610,400 805,275 805,125 3,221,100 -
Programmatic Expenditures
Traditional Medicaid Services Acute Care 50,901,700 25,450,800 25,450,800 - 50,901,700 -
ALTCS Services 243,220,500 115,493,200 117,444,111 ( 1,950,911) 243,220,500 -
TOTAL COUNTY EXPENDITURES 297,343,300 142,554,400 143,700,186 (1,145,786) 297,343,300 -
TOBACCO FUNDS
Programmatic Expenditures
Traditional Medicaid Services Acute Care - Medically Needy 38,295,800 19,594,400 19,147,900 4 46,500 38,295,800 -
Proposition 204 Services - Emergency Health Services 19,222,900 9,890,400 9,611,450 2 78,950 19,222,900 -
Proposition 204 Services - Proposition 204 Protection 40,367,900 20,654,900 20,183,950 4 70,950 40,367,900 -
Proposition 204 Services - ATLSF 100,000,000 - - - 100,000,000 -
TOTAL TOBACCO EXPENDITURES 197,886,600 50,139,700 48,943,300 1,196,400 197,886,600 -
OTHER
Administrative Expenditures
HCG 2,307,000 1,144,200 550,431 593,769 2,307,000 -
Prescription Drug Rebate Program 115,800 57,400 54,849 2,551 115,800 -
Programmatic Expenditures
Acute Care - Prescription Drug Rebate Program State Match 63,741,300 31,870,500 31,870,650 ( 150) 63,741,300 -
Acute Care - Prescription Drug Rebate Program Federal Authority 151,433,100 86,533,200 75,716,550 10,816,650 151,433,100 -
Long Term Care - Prescription Drug Rebate Program State Match 6,093,900 2,890,700 3,046,950 ( 156,250) 6,093,900 -
Long Term Care - Prescription Drug Rebate Program Federal Authority 13,959,200 6,621,500 6,979,600 ( 358,100) 13,959,200 -
Traditional Medicaid Services - TPL 194,700 - 558,429 ( 558,429) 194,700 -
ALTCS Services - TPL - - 617,078 (617,078) - -
KidsCare Services Premiums 1,958,500 1,116,800 723,247 393,553 1,958,500 -
Freedom to Work Premiums 44,200 21,600 20,355 1,245 44,200 -
DSH Voluntary - Local Government Match 26,034,300 14,827,500 14,827,418 8 2 26,034,300 -
GME Voluntary - Local Government Match 54,792,600 52,294,600 52,084,894 2 09,706 54,792,600 -
TOTAL OTHER EXPENDITURES 320,674,600 197,378,000 187,050,451 1 0,327,549 320,674,600 -
TOTAL
Administrative Expenditures 178,809,900 88,474,100 67,259,376 21,214,724 178,809,900 -
Acute Care 5,011,395,000 2,493,057,300 2,443,128,742 49,928,558 5,011,395,000 -
Long Term Care 1,177,910,000 548,936,600 548,522,259 414,341 1,177,910,000 -
TOTAL EXPENDITURES $ 6,368,114,900 $ 3,130,468,000 $ 3,058,910,377 $ 71,557,623 $ 6,368,114,900 $ -
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2013 APPROPRIATION STATUS REPORT
For the Period Ending December 31, 2012
APPROPRIATED EXPENDITURES BY FUNDING SOURCE
3
BUDGET BUDGET
YTD
GENERAL FUND:
Traditional Medicaid Services & Administrative $ 1,018,280,400 $ 472,470,300 $ 456,431,199
Proposition 204 Services & Administrative 212,105,000 155,797,400 139,163,205
KidsCare Services 5,132,600 2,875,400 2,223,217
ALTCS Services 162,594,300 77,207,900 77,346,707
TOTAL 1,398,112,300 708,351,000 675,164,328
FEDERAL:
Acute & Administrative 3,387,524,800 1,677,065,700 1,710,977,961
KidsCare Services 14,531,200 8,255,900 20,168,962
ALTCS Services 752,042,100 346,723,300 343,087,813
TOTAL 4,154,098,100 2,032,044,900 2,074,234,736
COUNTY:
Acute & Administrative 54,122,800 27,061,200 26,870,698
ALTCS Services 243,220,500 115,493,200 121,610,262
TOTAL 297,343,300 142,554,400 148,480,960
TOBACCO FUNDS:
Traditional Medicaid Services 38,295,800 19,594,400 19,147,900
Proposition 204 Services 159,590,800 30,545,300 29,795,400
TOTAL 197,886,600 50,139,700 48,943,300
OTHER:
Administrative 2,422,800 1,201,600 605,280
Acute Care - Prescription Drug Rebate Program 215,174,400 118,403,700 107,587,200
Long Term Care - Prescription Drug Rebate Program 20,053,100 9,512,200 10,026,550
Acute TPL - Note 1 194,700 - 558,429
LTC TPL - Note 1 - - 617,078
KidsCare TPL - Note 1 - - 4,650
Member Premiums - CHIP 1,958,500 1,116,800 686,565
Member Premiums - Freedom to Work 44,200 21,600 20,355
DSH and GME Voluntary - Local Government Match 80,826,900 67,122,100 -
TOTAL 320,674,600 197,378,000 120,106,106
TOTAL REVENUE $ 6,368,114,900 $ 3,130,468,000 $ 3,066,929,430
RECEIPTS
YTD
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2013 APPROPRIATION STATUS REPORT
APPROPRIATED REVENUE AND OTHER COLLECTIONS RECEIVED DETAIL SCHEDULE
For the Period Ending December 31, 2012
4
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
APPROPRIATION STATUS REPORT
FOOTNOTES
Note 1: Third Party Liability Collections: December 2012 December 2011 July 1, 2012 July 1, 2011
Gross Collections: December 31, 2012 December 31, 2011
Acute $ 326,641 $ 276,969 $ 3,403,019 $ 2,849,269
LTC 491,400 131,931 2,663,940 2,208,491
KidsCare 225 648 27,461 7,141
Total TPL Collections $ 818,266 $ 409,548 $ 6,094,420 $ 5,064,901
AHCCCS Net Collections (Net of Federal Share):
Expenditure Offsets:
Acute $ 40,497 $ - $ 558,429 $ -
LTC 118,825 29,713 617,078 449,181
KidsCare - 34 4,650 104
Total Expenditure Offsets 159,322 29,747 1,180,157 449,285
Acute - 46,105 - 415,853
KidsCare - 99 - 1,196
Total General Fund Transfers - 46,204 - 417,049
Total Net State Match Collections $ 159,322 $ 75,951 $ 1,180,157 $ 866,334
FY 13 Total
Note 2: Authorized Positions 1,370.1
Actual Positions as of December 31, 2012 952.6
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2013 APPROPRIATION STATUS REPORT
For the Period Ending December 31, 2012
State General Fund Transfers:
6
Note 3: Intergovernmental Service Agreement - State of Hawaii:
Beginning Balance July 1, 2012 $ 1 ,108,157
Revenues 4,063,803
Transfers-In 73,640
Total Revenues 4,137,443
Expenditures 2,659,036
Transfers-out 247,500
Total Expenditures 2,906,536
Ending Balance December 31, 2012 $ 2,339,065
Note 4:
Description Amount
Medicare Part B Premiums $ 7,602,830 HHS-OIG & CMS Questioned Cost
School Based Claiming Medicaid Administrative Costs 1 8,941,355 HHS-OIG & AHCCCS Self Reported
School Based Claiming Direct Services Costs 2 1,209,756 HHS-OIG
47,753,941
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
FY 2013 APPROPRIATION STATUS REPORT
For the Period Ending December 31, 2012
Summary of HHS Office of Inspector General Questioned Costs and CMS Deferrals and Disallowances Liabilities.
Schedule of Outstanding Liabilities
As of December 31, 2012
Type
Of the $2,339,065 ending balance, $1,574,891 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through January 2013.
7
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
APPROPRIATION STATUS REPORT
CASELOAD AND EXPENDITURES BY RATE CODE
JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending December 31, 2012
TITLE XIX EXPANSION AND CONVERSION
TITLE XIX BASE
CAPITATION - ACUTE 190,359,793 194,206,483 190,830,304 198,584,854 196,020,918 196,190,915 0 0 0 0 0 0 1,166,193,267
CAPITATION - LTC 152,688,740 153,257,940 153,496,210 156,112,691 156,399,312 156,313,475 0 0 0 0 0 0 928,268,367
MENTAL HEALTH - CHILD 22,434,436 22,521,934 22,580,932 22,444,615 22,234,589 22,135,453 0 0 0 0 0 0 134,351,958
MENTAL HEALTH - ADULT 21,724,207 21,839,863 21,978,162 21,933,714 21,801,438 21,689,670 0 0 0 0 0 0 130,967,054
MENTAL HEALTH - CMDP 11,559,924 11,798,044 11,931,083 12,341,768 12,456,490 12,316,703 0 0 0 0 0 0 72,404,012
MENTAL HEALTH - GENERAL 12,335,269 12,400,940 12,479,468 12,454,230 12,379,122 12,315,659 0 0 0 0 0 0 74,364,688
CHILDREN'S REHAB SERVICES 10,016,205 10,013,229 10,025,816 7,022,452 11,670,082 8,732,059 0 0 0 0 0 0 57,479,843
FEE FOR SERVICE - ACUTE 31,985,996 36,726,635 39,850,816 41,464,151 33,232,797 34,022,034 0 0 0 0 0 0 217,282,429
EMERGENCY SERVICES - FEDERAL 5,740,726 7,478,425 7,226,613 8,968,936 6,221,186 6,491,211 0 0 0 0 0 0 42,127,097
FFS - FAMILY PLANNING 5,108 3,829 3,866 6,345 2,555 5,372 0 0 0 0 0 0 27,074
FFS MEDICAID IN PUBLIC SCHOOLS 327,337 279,377 148,968 759,960 409,788 461,077 0 0 0 0 0 0 2,386,507
QMB - FEE FOR SERVICE 88,441 285,525 245,884 138,387 304,350 183,419 0 0 0 0 0 0 1,246,006
INPATIENT INMATES FFS 2,520 4,074 1,238 1,342 420 0 0 0 0 0 0 0 9,594
COCONINO COUNTY INMATES FFS 0 363 756 8,381 3,593 137 0 0 0 0 0 0 13,230
PIMA COUNTY INMATES FFS 395 2,876 4,572 2,066 471 270 0 0 0 0 0 0 10,649
PINAL COUNTY INMATES FFS 820 32 862 8,502 6,901 17,792 0 0 0 0 0 0 34,910
COCHISE COUNTY INMATES FFS 0 0 6,092 0 0 0 0 0 0 0 0 0 6,092
FEE FOR SERVICE - LTC 7,219,483 10,048,283 8,979,744 10,991,559 9,106,862 9,293,480 0 0 0 0 0 0 55,639,411
LFFS MEDICAID IN PUBLIC SCHOOLS 297,597 507,272 318,151 893,223 708,268 776,933 0 0 0 0 0 0 3,501,443
REINSURANCE - ACUTE 9,148,489 3,357,764 -1,432,506 15,192,830 6,848,413 7,097,419 0 0 0 0 0 0 40,212,410
REINSURANCE - LTC 4,414,167 664,131 1,228,404 1,892,163 464,469 5,791,755 0 0 0 0 0 0 14,455,090
SMIB - ACUTE 8,614,585 8,676,358 8,769,427 9,207,290 8,996,036 9,016,093 0 0 0 0 0 0 53,279,789
HIB - ACUTE 251,103 241,244 253,068 255,162 256,786 250,000 0 0 0 0 0 0 1,507,362
Q1 1,383,004 1,420,452 1,490,863 1,684,071 1,562,811 1,549,010 0 0 0 0 0 0 9,090,211
SMIB - LTC 2,556,162 2,541,266 2,562,213 2,567,109 2,566,410 2,583,418 0 0 0 0 0 0 15,376,578
HIB - LTC 280,549 276,939 272,429 271,437 271,753 272,812 0 0 0 0 0 0 1,645,919
498,553,276 493,253,435 525,207,240 503,925,817 SUBTOTAL 493,435,056 507,506,166 0 0 0 0 0 0 3,021,880,990
CAPITATION - ACUTE 73,970,153 72,789,552 69,764,657 69,411,726 68,014,622 66,689,065 0 0 0 0 0 0 420,639,777
MENTAL HEALTH - CHILD 265,490 266,950 269,446 267,602 269,753 270,138 0 0 0 0 0 0 1,609,379
MENTAL HEALTH - ADULT 19,358,785 19,034,155 18,640,299 18,242,021 17,906,184 17,586,052 0 0 0 0 0 0 110,767,495
MENTAL HEALTH - CMDP 964 0 0 0 964 0 0 0 0 0 0 0 1,928
MENTAL HEALTH - GENERAL 10,992,154 10,807,825 10,584,189 10,358,042 10,167,349 9,985,574 0 0 0 0 0 0 62,895,132
CHILDREN'S REHAB SERVICES 301,567 289,162 291,904 223,727 321,239 241,725 0 0 0 0 0 0 1,669,324
FEE FOR SERVICE - ACUTE 12,131,280 13,463,248 12,772,478 13,061,045 11,018,885 10,573,554 0 0 0 0 0 0 73,020,490
EMERGENCY SERVICES - FEDERAL 767,033 1,331,856 1,134,174 1,241,696 926,906 995,780 0 0 0 0 0 0 6,397,446
FFS MEDICAID IN PUBLIC SCHOOLS 3,143 2,446 1,527 5,915 4,234 2,997 0 0 0 0 0 0 20,262
9
JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
EXPENDITURE SUMMARY
For the Period Ending December 31, 2012
619,716,536 623,692,867 615,736,769 649,133,480 GRAND TOTAL 622,325,631 624,283,602 0 0 0 0 0 0 3,754,888,884
TITLE XXI - KidsCare
TITLE XXI - HIFA PARENTS
INPATIENT INMATES FFS 2,619 6,604 995 -14,234 36,816 2,624 0 0 0 0 0 0 35,424
COCONINO COUNTY INMATES FFS 403 130 0 0 0 0 0 0 0 0 0 0 533
MARICOPA CTY INMATES FFS 0 123 0 0 0 11,413 0 0 0 0 0 0 11,536
PIMA COUNTY INMATES FFS 11,916 4,882 0 6,479 6,176 19,900 0 0 0 0 0 0 49,353
PINAL COUNTY INMATES FFS 0 484 435 265 0 88 0 0 0 0 0 0 1,271
YUMA COUNTY INMATES FFS 0 0 0 0 0 -184 0 0 0 0 0 0 -184
COCHISE COUNTY INMATES FFS 0 0 2,597 0 0 177 0 0 0 0 0 0 2,773
REINSURANCE - ACUTE 2,154,316 48,314 873,670 2,581,905 1,592,527 1,588,170 0 0 0 0 0 0 8,838,903
SMIB - ACUTE 3,344,752 3,362,407 3,402,877 3,450,947 3,460,077 3,447,630 0 0 0 0 0 0 20,468,690
HIB - ACUTE 4,555 1,398 1,849 1,398 1,398 1,398 0 0 0 0 0 0 11,997
SUBTOTAL 123,309,129 121,409,534 117,741,096 118,838,535 113,727,132 111,416,101 0 0 0 0 0 0 706,441,527
TOTAL TITLE XIX 616,744,184 619,962,810 610,994,531 644,045,775 617,652,949 618,922,268 0 0 0 0 0 0 3,728,322,517
KidsCare - CAPITATION 1,890,882 2,664,196 3,409,987 3,575,194 3,238,745 3,793,541 0 0 0 0 0 0 18,572,546
KidsCare - FEE FOR SERVICE 76,314 54,880 41,405 77,893 94,508 64,369 0 0 0 0 0 0 409,370
KidsCare - MENTAL HEALTH 586,986 837,823 1,078,591 1,093,486 992,362 1,163,748 0 0 0 0 0 0 5,752,996
KidsCare - REINSURANCE 257,012 124 -83 163,858 61,330 118,459 0 0 0 0 0 0 600,699
KidsCare - CHILD REHAB SERVICES 161,158 173,033 212,337 177,274 285,737 221,218 0 0 0 0 0 0 1,230,756
SUBTOTAL 2,972,352 3,730,056 4,742,238 5,087,705 4,672,682 5,361,334 0 0 0 0 0 0 26,566,367
TOTAL TITLE XXI 2,972,352 3,730,056 4,742,238 5,087,705 4,672,682 5,361,334 0 0 0 0 0 0 26,566,367
10
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
ACUTE CAPITATION - AMOUNTS
1002 TANF 01-05 M & F WIT 0.00 104.41 104.41 109.10 109.10 109.10 0.00 0.00 0.00 0.00 0.00 0.00 536.12
1003 TANF 06-13 M & F WIT 111.86 111.86 111.86 120.39 230.59 120.39 0.00 0.00 0.00 0.00 0.00 0.00 806.95
1004 TANF 14-20 MALE WITH 0.00 163.60 163.60 161.14 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 488.34
1005 TANF 14-20 FEMALE WI 228.72 941.47 941.47 1,255.25 1,036.51 803.58 0.00 0.00 0.00 0.00 0.00 0.00 5,207.00
1006 TANF 21-44 MALE WITH 16,764.56 14,621.33 15,325.75 17,214.51 17,115.03 17,617.02 0.00 0.00 0.00 0.00 0.00 0.00 98,658.20
1007 TANF 21-44 FEMALE WI 73,648.98 70,089.48 69,937.70 69,101.98 64,585.40 63,810.76 0.00 0.00 0.00 0.00 0.00 0.00 411,174.30
1008 TANF 45-64 M & F WIT 64,823.98 60,166.65 62,119.72 64,164.10 62,600.12 65,264.28 0.00 0.00 0.00 0.00 0.00 0.00 379,138.85
1009 TANF 65+ M & F WITH 14,019.63 12,421.46 12,575.94 15,177.92 16,080.55 16,329.76 0.00 0.00 0.00 0.00 0.00 0.00 86,605.26
100C TANF 06-13 M & F WIT 0.00 0.00 0.00 0.00 53.80 0.00 0.00 0.00 0.00 0.00 0.00 0.00 53.80
100F TANF 21-44 MALE WITH 307.10 248.93 1,138.16 183.21 179.76 277.31 0.00 0.00 0.00 0.00 0.00 0.00 2,334.47
100G TANF 21-44 FEMALE WI 2,255.25 1,296.71 1,177.39 554.87 2,250.97 1,836.15 0.00 0.00 0.00 0.00 0.00 0.00 9,371.34
100H TANF 44-64 M & F WIT 1,949.33 1,935.66 177.60 553.65 939.47 374.42 0.00 0.00 0.00 0.00 0.00 0.00 5,930.13
100J TANF 65+ M & F WITH 658.86 43.80 115.44 568.08 1,049.59 43.89 0.00 0.00 0.00 0.00 0.00 0.00 2,479.66
1011 TANF <1 M & F NON-ME 6,855,702.89 6,936,653.52 6,879,519.69 7,187,048.69 7,093,597.08 7,121,067.37 0.00 0.00 0.00 0.00 0.00 0.00 42,073,589.24
1012 TANF 01-05 M & F NON 8,986,067.52 9,046,262.29 8,953,524.24 9,203,340.83 9,118,042.65 9,054,216.30 0.00 0.00 0.00 0.00 0.00 0.00 54,361,453.83
1013 TANF 06-13 M & F NON 12,176,083.88 12,337,815.29 12,329,525.00 12,747,656.27 12,713,234.03 12,721,427.83 0.00 0.00 0.00 0.00 0.00 0.00 75,025,742.30
1014 TANF 14-20 MALE NON- 3,314,054.87 3,358,445.46 3,363,411.20 3,444,069.65 3,450,636.12 3,475,437.33 0.00 0.00 0.00 0.00 0.00 0.00 20,406,054.63
1015 TANF 14-20 FEMALE NO 6,500,801.72 6,571,685.95 6,554,635.95 6,655,776.96 6,647,511.26 6,684,394.07 0.00 0.00 0.00 0.00 0.00 0.00 39,614,805.91
1016 TANF 21-44 MALE NON- 3,059,869.18 3,099,449.72 3,081,378.22 3,133,059.28 3,089,750.74 3,068,793.06 0.00 0.00 0.00 0.00 0.00 0.00 18,532,300.20
1017 TANF 21-44 FEMALE NO 19,136,282.09 19,435,857.63 19,376,953.48 19,555,787.62 19,449,261.50 19,369,270.96 0.00 0.00 0.00 0.00 0.00 0.00 116,323,413.28
1018 TANF 45-64 M & F NON 5,912,166.57 6,002,373.36 5,989,185.76 6,290,686.83 6,268,888.10 6,280,489.73 0.00 0.00 0.00 0.00 0.00 0.00 36,743,790.35
1019 TANF 65+ M & F NON-M 17,066.43 19,175.74 16,656.54 18,421.30 15,726.84 14,250.52 0.00 0.00 0.00 0.00 0.00 0.00 101,297.37
101A TANF < 1 M & F NON-M 351,640.07 426,760.88 332,188.99 361,174.93 342,019.95 390,618.00 0.00 0.00 0.00 0.00 0.00 0.00 2,204,402.82
101B TANF 01-05 M & F NON 185,594.41 209,127.68 159,361.36 180,723.50 190,372.88 197,240.02 0.00 0.00 0.00 0.00 0.00 0.00 1,122,419.85
101C TANF 06-13 M & F NON 193,161.74 230,842.03 171,029.39 187,370.05 203,891.38 201,887.83 0.00 0.00 0.00 0.00 0.00 0.00 1,188,182.42
101D TANF 14-20 MALE NON- 116,861.71 145,619.63 97,775.96 107,660.19 113,878.95 126,750.61 0.00 0.00 0.00 0.00 0.00 0.00 708,547.05
101E TANF 14-20 FEMALE NO 203,498.27 245,770.32 184,780.52 204,145.72 189,881.06 202,747.22 0.00 0.00 0.00 0.00 0.00 0.00 1,230,823.11
101F TANF 21-44 MALE NON- 169,066.80 186,332.54 139,906.53 153,541.13 154,912.92 178,412.65 0.00 0.00 0.00 0.00 0.00 0.00 982,172.57
101G TANF 21-44 FEMALE NO 675,010.64 762,852.95 569,850.73 601,026.19 623,028.74 655,838.72 0.00 0.00 0.00 0.00 0.00 0.00 3,887,607.97
101H TANF 44-64 M & F NON 172,588.82 210,896.33 129,249.10 144,831.99 153,151.64 172,650.05 0.00 0.00 0.00 0.00 0.00 0.00 983,367.93
101J TANF 65+ N & F NON-M 386.70 1,755.10 639.14 1,026.64 0.00 46.46 0.00 0.00 0.00 0.00 0.00 0.00 3,854.04
1026 TANF 21-44 MALE WITH 459.16 459.16 687.36 703.36 255.70 348.34 0.00 0.00 0.00 0.00 0.00 0.00 2,913.08
1027 TANF 21-44 FEMALE WI 2,234.54 1,642.75 1,879.09 1,636.16 1,851.61 1,618.68 0.00 0.00 0.00 0.00 0.00 0.00 10,862.83
1028 TANF 45-64 M & F WIT 2,666.01 3,029.39 3,411.96 2,816.45 2,806.01 3,198.54 0.00 0.00 0.00 0.00 0.00 0.00 17,928.36
1029 TANF 65+ M & F WITH 0.00 0.00 0.00 0.00 340.01 340.01 0.00 0.00 0.00 0.00 0.00 0.00 680.02
102F TANF 21-44 MALE WITH 0.00 0.00 0.00 0.00 0.00 57.97 0.00 0.00 0.00 0.00 0.00 0.00 57.97
102G TANF 21-44 FEMALE WI 114.14 0.00 148.98 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 263.12
2100 SSI AGED WITH MEDICA 517,424.68 511,239.64 504,412.65 540,081.44 543,680.99 546,864.77 0.00 0.00 0.00 0.00 0.00 0.00 3,163,704.17
11
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
ACUTE CAPITATION - AMOUNTS
210Z SSI AGED WITH MEDICA 49,877.76 41,039.73 22,081.91 23,413.54 21,605.57 28,528.68 0.00 0.00 0.00 0.00 0.00 0.00 186,547.19
2110 SSI AGED NON-MEDICAR 3,642,062.48 3,619,124.29 3,607,498.15 3,702,582.91 3,689,786.85 3,664,467.92 0.00 0.00 0.00 0.00 0.00 0.00 21,925,522.60
211Z SSI AGED NON-MEDICAR 78,228.86 86,121.22 72,367.88 82,693.05 81,900.02 86,554.35 0.00 0.00 0.00 0.00 0.00 0.00 487,865.38
2120 SSI AGED WITH QMB 2,450,128.66 2,473,631.98 2,476,928.12 2,626,796.19 2,618,090.03 2,617,252.70 0.00 0.00 0.00 0.00 0.00 0.00 15,262,827.68
212Z SSI AGED WITH QMB PP 13,620.61 13,486.63 9,335.42 11,520.05 10,119.16 11,262.06 0.00 0.00 0.00 0.00 0.00 0.00 69,343.93
2200 SSI DISABLED WITH ME 436,041.82 439,027.36 439,230.09 471,982.70 472,337.19 481,746.84 0.00 0.00 0.00 0.00 0.00 0.00 2,740,366.00
220Z SSI DISABLED WITH ME 60,328.84 53,118.37 35,014.97 40,775.15 30,176.20 36,098.28 0.00 0.00 0.00 0.00 0.00 0.00 255,511.81
2210 SSI DISABLED NON-MED 39,098,075.71 39,278,773.52 39,494,487.91 41,108,076.70 41,225,709.73 41,416,680.96 0.00 0.00 0.00 0.00 0.00 0.00 241,621,804.53
221Z SSI DISABLED NON-MED 905,477.22 935,481.04 918,214.05 836,277.81 835,299.21 881,002.95 0.00 0.00 0.00 0.00 0.00 0.00 5,311,752.28
2220 SSI DISABLED WITH QM 3,286,411.17 3,316,754.92 3,341,589.73 3,521,559.66 3,544,533.98 3,561,434.59 0.00 0.00 0.00 0.00 0.00 0.00 20,572,284.05
222Z SSI DISABLED WITH QM 4,052.86 6,619.25 5,377.18 3,236.55 2,377.94 4,789.18 0.00 0.00 0.00 0.00 0.00 0.00 26,452.96
2300 SSI BLIND WITH MEDIC 2,473.77 2,529.04 2,582.99 2,830.52 2,970.48 3,035.95 0.00 0.00 0.00 0.00 0.00 0.00 16,422.75
230Z SSI BLIND WITH MEDIC 0.00 854.74 18.73 0.00 0.00 136.83 0.00 0.00 0.00 0.00 0.00 0.00 1,010.30
2310 SSI BLIND NON-MEDICA 275,071.09 276,294.24 280,960.75 290,115.63 287,531.05 291,399.85 0.00 0.00 0.00 0.00 0.00 0.00 1,701,372.61
231Z SSI BLIND NON-MEDICA 8,913.22 4,298.33 901.83 1,014.17 5,158.95 5,812.43 0.00 0.00 0.00 0.00 0.00 0.00 26,098.93
2320 SSI BLIND WITH QMB 27,410.74 27,253.01 27,030.42 29,444.70 29,406.12 29,412.46 0.00 0.00 0.00 0.00 0.00 0.00 169,957.45
232Z SSI BLIND WITH QMB P 0.00 7.86 40.59 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 48.45
4303 SOBRA CHILD 06-13 M 104.41 104.41 104.41 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 313.23
4304 SOBRA CHILD 14-20 MA 132.27 132.27 132.27 133.82 133.82 133.82 0.00 0.00 0.00 0.00 0.00 0.00 798.27
4305 SOBRA CHILD 14-20 FE 0.00 0.00 0.00 235.50 454.24 454.24 0.00 0.00 0.00 0.00 0.00 0.00 1,143.98
4311 SOBRA CHILD <1 M & F 14,984,943.93 15,071,699.59 14,923,681.78 15,805,371.91 15,681,964.08 15,708,497.27 0.00 0.00 0.00 0.00 0.00 0.00 92,176,158.56
4312 SOBRA CHILD 01-05 M 10,028,810.89 10,127,192.94 9,999,598.45 10,270,667.15 10,141,005.07 10,050,286.93 0.00 0.00 0.00 0.00 0.00 0.00 60,617,561.43
4313 SOBRA CHILD 06-13 M 12,092,099.25 12,235,938.72 12,161,428.16 12,553,972.05 12,491,512.51 12,433,828.92 0.00 0.00 0.00 0.00 0.00 0.00 73,968,779.61
4314 SOBRA CHILD 14-20 MA 4,320,791.44 4,370,768.52 4,327,896.88 4,366,947.45 4,334,627.47 4,305,103.65 0.00 0.00 0.00 0.00 0.00 0.00 26,026,135.41
4315 SOBRA CHILD 14-20 FE 6,611,351.80 6,712,363.31 6,643,910.30 6,672,739.14 6,618,535.18 6,561,743.32 0.00 0.00 0.00 0.00 0.00 0.00 39,820,643.05
431A SOBRA CHILD < 1 M & 538,328.21 682,638.80 481,416.75 515,400.24 542,950.47 550,150.11 0.00 0.00 0.00 0.00 0.00 0.00 3,310,884.58
431B SOBRA CHILD 01-05 M 277,266.28 299,519.39 206,180.13 234,941.75 264,117.13 277,618.77 0.00 0.00 0.00 0.00 0.00 0.00 1,559,643.45
431C SOBRA CHILD 6-13 M&F 258,266.43 298,430.48 211,803.88 230,004.05 234,189.21 237,456.72 0.00 0.00 0.00 0.00 0.00 0.00 1,470,150.77
431D SOBRA CHILD 14-20 MA 197,126.97 237,971.81 175,129.51 184,830.23 185,750.23 175,611.73 0.00 0.00 0.00 0.00 0.00 0.00 1,156,420.48
431E SOBRA CHILD 14-20 FE 246,489.14 300,293.23 205,760.34 217,606.81 222,616.15 210,978.59 0.00 0.00 0.00 0.00 0.00 0.00 1,403,744.26
5007 SOBRA PREG 21-44 FEM 13,465.38 14,451.01 13,476.95 14,096.90 13,039.16 14,170.66 0.00 0.00 0.00 0.00 0.00 0.00 82,700.06
5008 SOBRA PREG 45-64 FEM 0.00 0.00 0.00 0.00 760.16 348.44 0.00 0.00 0.00 0.00 0.00 0.00 1,108.60
500G SOBRA PREG 21-44 FEM 342.47 1,249.48 107.55 1,142.12 1,080.03 403.56 0.00 0.00 0.00 0.00 0.00 0.00 4,325.21
5013 SOBRA PREG 09-13 FEM 236.10 192.22 93.48 141.56 93.11 38.07 0.00 0.00 0.00 0.00 0.00 0.00 794.54
5015 SOBRA PREG 14-20 FEM 872,827.32 908,923.38 875,384.17 874,719.53 834,157.68 795,443.41 0.00 0.00 0.00 0.00 0.00 0.00 5,161,455.49
5017 SOBRA PREG 21-44 FEM 2,487,935.39 2,570,888.72 2,552,498.51 2,564,948.80 2,488,265.99 2,400,811.31 0.00 0.00 0.00 0.00 0.00 0.00 15,065,348.72
5018 SOBRA PREG 45-64 FEM 6,675.42 7,913.95 8,542.21 9,983.67 7,529.04 7,775.66 0.00 0.00 0.00 0.00 0.00 0.00 48,419.95
501C SOBRA PREG 09-13 FEM 46.68 1.98 0.00 31.61 0.00 94.83 0.00 0.00 0.00 0.00 0.00 0.00 175.10
12
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
ACUTE CAPITATION - AMOUNTS
501E SOBRA PREG 14-20 FEM 95,533.54 106,173.39 78,527.72 76,684.25 79,869.36 85,570.07 0.00 0.00 0.00 0.00 0.00 0.00 522,358.33
501G SOBRA PREG 21-44 FEM 285,412.40 308,231.54 224,099.42 226,074.90 232,896.14 254,529.93 0.00 0.00 0.00 0.00 0.00 0.00 1,531,244.33
501H SOBRA PREG 45-64 FEM 1,292.93 1,753.90 499.31 26.98 592.87 1,625.41 0.00 0.00 0.00 0.00 0.00 0.00 5,791.40
5027 SOBRA PREG 21-44 FEM 646.65 400.96 459.98 0.00 0.00 415.96 0.00 0.00 0.00 0.00 0.00 0.00 1,923.55
502G SOBRA PREG 21-44 FEM 0.00 48.06 0.00 0.00 0.00 53.28 0.00 0.00 0.00 0.00 0.00 0.00 101.34
5500 SOBRA FPS FEMALE WIT 14.79 14.79 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 29.58
5510 SOBRA FPS FEMALE WIT 55,831.36 55,597.33 57,883.20 56,378.76 58,714.70 60,571.35 0.00 0.00 0.00 0.00 0.00 0.00 344,976.70
172,437,717.37 174,793,502.43 172,886,276.96 178,521,147.89 177,824,807.33 SUBTOTAL: 177,887,885.74 0.00 0.00 0.00 0.00 0.00 0.00 1,054,351,337.72
9910 TANF & SOBRA CHILDRE 6,036,364.92 6,869,320.76 5,885,184.02 6,684,603.19 6,198,200.11 6,135,633.60 0.00 0.00 0.00 0.00 0.00 0.00 37,809,306.60
9920 SSI W/MEDICARE KICK 58,173.94 63,849.25 46,556.52 54,941.44 49,707.35 73,971.25 0.00 0.00 0.00 0.00 0.00 0.00 347,199.75
9921 SSI W/O MEDICARE KIC 239,924.06 134,265.05 192,071.15 333,799.21 263,267.01 243,302.65 0.00 0.00 0.00 0.00 0.00 0.00 1,406,629.13
9950 S.O.B.R.A. KICK PAYM 11,148,663.30 11,914,341.84 11,384,743.30 12,524,797.84 11,228,055.61 11,394,310.83 0.00 0.00 0.00 0.00 0.00 0.00 69,594,912.72
SUBTOTAL: 17,483,126.22 18,981,776.90 17,508,554.99 19,598,141.68 17,739,230.08 17,847,218.33 0.00 0.00 0.00 0.00 0.00 0.00 109,158,048.20
3100 TRANSPLANT OPTION 1 33.00 33.00 7.98 46.84 82.50 66.00 0.00 0.00 0.00 0.00 0.00 0.00 269.32
310Z TRANSPLANT OPTION 1 0.00 0.00 0.00 101.66 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 101.66
SUBTOTAL: 33.00 33.00 7.98 148.50 82.50 66.00 0.00 0.00 0.00 0.00 0.00 0.00 370.98
1106 TANF EXPANDED 21-44 111,176.00 111,701.00 111,232.83 112,734.76 113,399.71 112,099.96 0.00 0.00 0.00 0.00 0.00 0.00 672,344.26
1107 TANF EXPANDED 21-44 371,722.03 378,930.51 375,180.33 376,153.76 377,527.59 380,054.60 0.00 0.00 0.00 0.00 0.00 0.00 2,259,568.82
1108 TANF EXPANDED 45-64 747,373.80 769,963.19 766,800.84 810,616.56 817,146.39 816,092.39 0.00 0.00 0.00 0.00 0.00 0.00 4,727,993.17
1109 TANF EXPANDED 65+ M& 201,780.57 204,164.26 204,250.59 217,456.86 216,993.31 221,696.55 0.00 0.00 0.00 0.00 0.00 0.00 1,266,342.14
110F TANF EXPANDED 21-44 1,975.53 2,180.22 2,446.15 2,505.29 3,466.91 3,762.48 0.00 0.00 0.00 0.00 0.00 0.00 16,336.58
110G TANF EXPANDED 21-44 6,710.50 12,081.34 6,740.55 4,655.79 8,640.26 7,398.59 0.00 0.00 0.00 0.00 0.00 0.00 46,227.03
110H TANF EXPANDED 45-64 13,496.93 16,609.32 10,395.48 14,933.34 11,354.90 12,563.97 0.00 0.00 0.00 0.00 0.00 0.00 79,353.94
110J TANF EXPANDED 65+ M& 1,020.53 4,553.94 1,307.36 3,644.92 3,302.03 3,486.71 0.00 0.00 0.00 0.00 0.00 0.00 17,315.49
1111 TANF EXPANDED <1 M&F 16,028.40 14,008.29 14,179.82 14,648.70 12,730.11 12,696.21 0.00 0.00 0.00 0.00 0.00 0.00 84,291.53
1112 TANF EXPANDED 01-05 100,923.44 102,108.10 100,608.80 104,127.07 104,431.13 100,377.10 0.00 0.00 0.00 0.00 0.00 0.00 612,575.64
1113 TANF EXPANDED 06-13 351,786.16 355,809.55 359,898.10 373,886.98 375,793.14 379,140.70 0.00 0.00 0.00 0.00 0.00 0.00 2,196,314.63
1114 TANF EXPANDED 14-20 245,957.73 244,644.48 239,634.75 242,297.59 241,861.84 241,697.86 0.00 0.00 0.00 0.00 0.00 0.00 1,456,094.25
1115 TANF EXPANDED 14-20 703,518.73 714,244.70 701,237.71 698,032.68 699,656.94 694,735.32 0.00 0.00 0.00 0.00 0.00 0.00 4,211,426.08
1116 TANF EXPANDED 21-44 3,703,188.98 3,744,084.91 3,681,536.78 3,696,658.61 3,639,619.78 3,603,423.84 0.00 0.00 0.00 0.00 0.00 0.00 22,068,512.90
1117 TANF EXPANDED 21-44 12,016,169.81 12,188,467.39 12,004,385.00 12,062,515.02 11,982,089.26 11,974,754.71 0.00 0.00 0.00 0.00 0.00 0.00 72,228,381.19
1118 TANF EXPANDED 45-64 6,286,516.59 6,343,625.04 6,309,495.27 6,635,210.48 6,633,615.02 6,568,824.05 0.00 0.00 0.00 0.00 0.00 0.00 38,777,286.45
1119 TANF EXPANDED 65+ M& 17,317.09 14,998.89 16,886.97 14,302.40 12,838.70 14,065.94 0.00 0.00 0.00 0.00 0.00 0.00 90,409.99
111A TANF EXPANDED <1 M&F 6,357.68 4,868.80 808.57 1,242.67 2,798.45 2,376.01 0.00 0.00 0.00 0.00 0.00 0.00 18,452.18
111B TANF EXPANDED 01-05 3,385.38 2,644.84 1,758.76 2,857.93 1,765.94 3,016.79 0.00 0.00 0.00 0.00 0.00 0.00 15,429.64
111C TANF EXPANDED 06-13 9,508.35 9,391.23 5,759.12 7,347.76 6,676.80 6,056.13 0.00 0.00 0.00 0.00 0.00 0.00 44,739.39
111D TANF EXPANDED 14-20 15,860.31 17,993.36 14,188.22 12,468.73 15,448.95 14,849.45 0.00 0.00 0.00 0.00 0.00 0.00 90,809.02
13
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
ACUTE CAPITATION - AMOUNTS
111E TANF EXPANDED 14-20 34,611.27 39,562.47 30,344.81 30,694.99 27,061.05 29,068.30 0.00 0.00 0.00 0.00 0.00 0.00 191,342.89
111F TANF EXPANDED 21-44 211,539.11 240,316.84 170,286.57 191,270.95 192,351.82 218,832.95 0.00 0.00 0.00 0.00 0.00 0.00 1,224,598.24
111G TANF EXPANDED 21-44 500,111.29 605,565.18 423,263.75 457,875.62 471,240.87 485,932.30 0.00 0.00 0.00 0.00 0.00 0.00 2,943,989.01
111H TANF EXPANDED 45-64 236,076.14 277,343.36 211,141.38 214,303.01 212,148.56 197,405.14 0.00 0.00 0.00 0.00 0.00 0.00 1,348,417.59
111J TANF EXPANDED 65+ M& 1,723.19 2,205.78 2,643.93 459.00 940.14 2,003.58 0.00 0.00 0.00 0.00 0.00 0.00 9,975.62
1126 TANF EXPANDED 21-44 4,722.29 4,495.32 4,768.94 4,614.84 4,565.26 4,972.05 0.00 0.00 0.00 0.00 0.00 0.00 28,138.70
1127 TANF EXPANDED 21-44 15,206.49 15,067.78 14,482.45 14,954.18 14,789.29 13,613.29 0.00 0.00 0.00 0.00 0.00 0.00 88,113.48
1128 TANF EXPANDED 45-64 42,367.84 44,499.45 44,500.67 45,048.22 43,248.07 45,498.91 0.00 0.00 0.00 0.00 0.00 0.00 265,163.16
1129 TANF EXPANDED 65+ M& 14,384.12 14,435.59 12,832.27 15,104.02 14,362.32 16,231.15 0.00 0.00 0.00 0.00 0.00 0.00 87,349.47
112F TANF EXPANDED 21-44 125.65 34.24 70.76 160.74 0.00 36.89 0.00 0.00 0.00 0.00 0.00 0.00 428.28
112G TANF EXPANDED 21-44 439.18 169.74 43.45 292.37 244.77 332.04 0.00 0.00 0.00 0.00 0.00 0.00 1,521.55
112H TANF EXPANDED 45-64 352.02 1,405.97 761.43 0.00 439.42 61.79 0.00 0.00 0.00 0.00 0.00 0.00 3,020.63
2400 SSI AGED EXPANDED WI 42,731.13 48,808.07 40,991.83 46,805.06 51,282.72 47,466.59 0.00 0.00 0.00 0.00 0.00 0.00 278,085.40
240Z SSI AGED EXPANDED WI 50,184.82 48,389.51 30,529.88 28,284.62 25,885.00 22,204.29 0.00 0.00 0.00 0.00 0.00 0.00 205,478.12
2410 SSI AGED EXPANDED NO 958,476.59 942,870.18 890,182.74 896,916.91 886,247.55 842,470.86 0.00 0.00 0.00 0.00 0.00 0.00 5,417,164.83
241Z SSI AGED EXPANDED NO 27,951.85 27,650.02 22,348.38 30,227.42 25,585.39 27,384.63 0.00 0.00 0.00 0.00 0.00 0.00 161,147.69
2420 SSI AGED EXPANDED WI 2,590,938.69 2,608,109.39 2,618,095.52 2,755,058.05 2,752,204.36 2,771,704.07 0.00 0.00 0.00 0.00 0.00 0.00 16,096,110.08
242Z SSI AGED EXPANDED WI 22,429.25 21,222.86 15,253.06 21,585.29 15,016.80 18,722.26 0.00 0.00 0.00 0.00 0.00 0.00 114,229.52
2520 SSI BLIND EXPANDED W 992.19 1,254.30 1,261.89 1,459.86 1,459.86 1,459.86 0.00 0.00 0.00 0.00 0.00 0.00 7,887.96
252Z SSI BLIND EXPANDED W 0.00 7.06 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 7.06
2600 SSI DISABLED EXPANDE 63,324.49 64,667.69 65,361.69 66,841.71 69,167.57 67,230.10 0.00 0.00 0.00 0.00 0.00 0.00 396,593.25
260Z SSI DISABLED EXPANDE 48,040.34 44,118.56 31,304.77 28,142.63 29,122.22 22,783.68 0.00 0.00 0.00 0.00 0.00 0.00 203,512.20
2610 SSI DISABLED EXPANDE 3,169,914.42 3,090,994.97 2,942,752.65 2,856,547.32 2,767,763.28 2,628,199.58 0.00 0.00 0.00 0.00 0.00 0.00 17,456,172.22
261Z SSI DISABLED EXPANDE 52,209.17 55,417.91 42,593.41 43,730.07 54,957.08 47,437.77 0.00 0.00 0.00 0.00 0.00 0.00 296,345.41
2620 SSI DISABLED EXPANDE 960,450.36 983,446.68 1,007,025.10 1,079,992.40 1,098,870.81 1,118,375.75 0.00 0.00 0.00 0.00 0.00 0.00 6,248,161.10
262Z SSI DISABLED EXPANDE 6,001.22 6,573.29 4,935.68 6,534.11 3,576.55 2,046.86 0.00 0.00 0.00 0.00 0.00 0.00 29,667.71
33,987,077.65 34,445,705.57 33,556,509.01 34,245,201.29 SUBTOTAL: 34,043,687.92 33,804,644.05 0.00 0.00 0.00 0.00 0.00 0.00 204,082,825.49
9911 SB PAYMENT FOR TANF 402,419.02 464,961.55 324,818.42 340,437.77 343,301.41 378,183.06 0.00 0.00 0.00 0.00 0.00 0.00 2,254,121.23
9922 SB PAYMENT FOR SSI E 11,633.48 11,228.08 5,838.94 0.00 11,800.88 6,167.47 0.00 0.00 0.00 0.00 0.00 0.00 46,668.85
9923 SB PAYMENT FOR SSI E 29,604.21 28,713.64 23,831.47 30,340.10 24,026.64 12,334.94 0.00 0.00 0.00 0.00 0.00 0.00 148,851.00
SUBTOTAL: 443,656.71 504,903.27 354,488.83 370,777.87 379,128.93 396,685.47 0.00 0.00 0.00 0.00 0.00 0.00 2,449,641.08
3306 AHC CARE MALE 21-44 2,533.72 2,152.79 2,152.79 1,743.03 2,159.44 2,159.44 0.00 0.00 0.00 0.00 0.00 0.00 12,901.21
3307 AHC CARE FEMALE 21-4 1,262.03 829.78 440.20 449.44 830.51 449.44 0.00 0.00 0.00 0.00 0.00 0.00 4,261.40
3308 AHC CARE M&F 45-64 W 5,063.45 5,587.30 5,241.71 5,354.33 5,354.33 4,972.95 0.00 0.00 0.00 0.00 0.00 0.00 31,574.07
3309 AHC CARE M&F 65+ W/ 3,725.65 4,196.91 4,071.24 4,468.88 4,468.88 4,119.58 0.00 0.00 0.00 0.00 0.00 0.00 25,051.14
330G AHC CARE FEMALE 21-4 0.00 0.00 0.00 0.00 1,127.39 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,127.39
330J AHC CARE M&F 65+ W/ 0.00 1,743.11 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,743.11
14
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
ACUTE CAPITATION - AMOUNTS
3314 AHC CARE MALE 14-20 409,536.65 395,081.23 381,542.71 371,741.50 367,078.06 365,462.88 0.00 0.00 0.00 0.00 0.00 0.00 2,290,443.03
3315 AHC CARE FEMALE 14-2 509,577.91 488,841.18 482,074.37 469,641.08 477,638.70 466,501.21 0.00 0.00 0.00 0.00 0.00 0.00 2,894,274.45
3316 AHC CARE MALE 21-44 1,839,320.23 1,703,301.06 1,533,437.90 1,437,292.40 1,363,456.62 1,303,241.73 0.00 0.00 0.00 0.00 0.00 0.00 9,180,049.94
3317 AHC CARE FEMALE 21-4 1,905,878.09 1,783,456.26 1,609,842.59 1,524,009.39 1,455,853.26 1,382,014.20 0.00 0.00 0.00 0.00 0.00 0.00 9,661,053.79
3318 AHC CARE M&F 45-64 N 5,404,381.66 5,165,385.30 4,895,002.07 4,747,676.26 4,563,511.54 4,400,933.55 0.00 0.00 0.00 0.00 0.00 0.00 29,176,890.38
3319 AHC CARE M&F 65+ NO 0.00 0.00 0.00 0.00 0.00 414.49 0.00 0.00 0.00 0.00 0.00 0.00 414.49
331A AHC CARE M&F < 1 NO 0.00 0.00 0.00 254.49 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 254.49
331D AHC CARE MALE 14-20 3,661.11 6,269.23 4,574.73 6,803.77 3,257.48 8,225.24 0.00 0.00 0.00 0.00 0.00 0.00 32,791.56
331E AHC CARE FEMALE 14-2 6,922.86 10,011.27 10,246.13 7,182.04 5,011.49 3,938.86 0.00 0.00 0.00 0.00 0.00 0.00 43,312.65
331F AHC CARE MALE 21-44 21,036.83 14,713.01 8,036.69 15,472.29 9,453.12 6,148.15 0.00 0.00 0.00 0.00 0.00 0.00 74,860.09
331G AHC CARE FEMALE 21-4 14,657.23 26,667.61 11,073.50 10,257.18 7,211.57 10,135.87 0.00 0.00 0.00 0.00 0.00 0.00 80,002.96
331H AHC CARE M&F 45-64 N 43,548.23 39,317.17 26,663.46 43,018.76 14,400.54 17,670.51 0.00 0.00 0.00 0.00 0.00 0.00 184,618.67
331J AHC CARE M&F 65+ NO 0.00 0.00 0.00 3,053.88 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 3,053.88
3326 AHC CARE MALE 21-44 2,308.94 2,308.94 2,308.94 2,283.12 2,697.61 2,697.61 0.00 0.00 0.00 0.00 0.00 0.00 14,605.16
3327 AHC CARE FEMALE 21-4 691.18 691.18 697.88 329.81 769.36 769.36 0.00 0.00 0.00 0.00 0.00 0.00 3,948.77
3328 AHC CARE M&F 45-64 W 4,889.63 4,889.63 6,512.37 6,923.12 7,286.16 6,896.81 0.00 0.00 0.00 0.00 0.00 0.00 37,397.72
3329 AHC CARE M&F 65+ W/ 872.45 -1,108.45 821.83 842.00 842.00 842.00 0.00 0.00 0.00 0.00 0.00 0.00 3,111.83
10,179,867.85 9,654,334.51 SUBTOTAL: 8,984,741.11 8,658,796.77 8,292,408.06 7,987,593.88 0.00 0.00 0.00 0.00 0.00 0.00 53,757,742.18
9933 SB PAYMENT FOR AHCCS 52,056.26 34,049.36 40,717.58 24,142.37 36,391.73 35,621.16 0.00 0.00 0.00 0.00 0.00 0.00 222,978.46
SUBTOTAL: 52,056.26 34,049.36 40,717.58 24,142.37 36,391.73 35,621.16 0.00 0.00 0.00 0.00 0.00 0.00 222,978.46
3606 AHC CARE/MI MALE 21- 2,232.19 3,045.37 1,944.56 2,842.24 2,744.21 2,744.21 0.00 0.00 0.00 0.00 0.00 0.00 15,552.78
3607 AHC CARE/MI FEMALE 2 847.77 847.77 407.89 414.49 854.04 854.04 0.00 0.00 0.00 0.00 0.00 0.00 4,226.00
3608 AHC CARE/MI M&F 45-6 3,315.87 3,176.43 2,593.80 4,147.84 4,412.33 4,492.95 0.00 0.00 0.00 0.00 0.00 0.00 22,139.22
360F AHC CARE/MI MALE 21- 0.00 2,290.41 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2,290.41
360H AHC CARE/MI M&F 45-6 0.00 4,162.14 0.00 0.00 0.00 492.56 0.00 0.00 0.00 0.00 0.00 0.00 4,654.70
3614 AHC CARE/MI MALE 14- 2,802,562.13 2,736,163.07 2,673,681.09 2,653,495.19 2,611,214.50 2,570,823.27 0.00 0.00 0.00 0.00 0.00 0.00 16,047,939.25
3615 AHC CARE/MI FEMALE 1 2,534,504.87 2,489,426.29 2,408,309.81 2,389,672.98 2,360,347.13 2,336,679.40 0.00 0.00 0.00 0.00 0.00 0.00 14,518,940.48
3616 AHC CARE/MI MALE 21- 7,008,942.61 6,576,717.62 6,177,395.83 5,908,812.41 5,628,237.16 5,355,283.44 0.00 0.00 0.00 0.00 0.00 0.00 36,655,389.07
3617 AHC CARE/MI FEMALE 2 4,580,327.13 4,347,656.71 4,087,452.63 3,939,900.70 3,775,615.87 3,602,003.47 0.00 0.00 0.00 0.00 0.00 0.00 24,332,956.51
3618 AHC CARE/MI M&F 45-6 11,992,659.38 11,598,170.61 11,176,323.13 10,907,114.85 10,580,368.03 10,245,488.36 0.00 0.00 0.00 0.00 0.00 0.00 66,500,124.36
3619 AHC CARE/MI M&F 65+ 407.89 407.89 407.89 414.49 414.49 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2,052.65
361D AHC CARE/MI MALE 14- 31,100.75 28,087.65 21,661.87 26,471.17 33,280.03 28,947.01 0.00 0.00 0.00 0.00 0.00 0.00 169,548.48
361E AHC CARE/MI FEMALE 1 29,587.70 47,453.01 25,089.87 28,444.17 19,314.21 34,902.45 0.00 0.00 0.00 0.00 0.00 0.00 184,791.41
361F AHC CARE/MI MALE 21- 54,151.33 49,463.90 45,237.54 57,589.44 29,046.58 57,693.23 0.00 0.00 0.00 0.00 0.00 0.00 293,182.02
361G AHC CARE/MI FEMALE 2 37,475.21 33,533.51 31,461.20 27,848.17 30,775.61 26,660.40 0.00 0.00 0.00 0.00 0.00 0.00 187,754.10
361H AHC CARE/MI M&F 45-6 77,132.83 72,579.04 60,178.66 74,207.92 45,901.40 67,945.85 0.00 0.00 0.00 0.00 0.00 0.00 397,945.70
361J AHC CARE/MI M&F 65+ 0.00 0.00 0.00 0.00 3,817.35 0.00 0.00 0.00 0.00 0.00 0.00 0.00 3,817.35
15
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
ACUTE CAPITATION - AMOUNTS
3626 AHC CARE/MI MALE 21- 722.90 722.90 722.90 341.43 341.43 341.43 0.00 0.00 0.00 0.00 0.00 0.00 3,192.99
3628 AHC CARE/MI M&F 45-6 0.00 0.00 0.00 0.00 0.00 386.47 0.00 0.00 0.00 0.00 0.00 0.00 386.47
29,155,970.56 27,993,904.32 26,712,868.67 26,021,717.49 SUBTOTAL: 25,126,684.37 24,335,738.54 0.00 0.00 0.00 0.00 0.00 0.00 159,346,883.95
9936 SB PAYMENT FOR AHC C 151,524.24 156,655.41 115,331.98 91,090.11 136,321.39 128,782.25 0.00 0.00 0.00 0.00 0.00 0.00 779,705.38
SUBTOTAL: 151,524.24 156,655.41 115,331.98 91,090.11 136,321.39 128,782.25 0.00 0.00 0.00 0.00 0.00 0.00 779,705.38
4517 BC PATIENT FEMALE 21 3,687.33 3,478.64 3,289.61 3,423.05 3,492.39 4,241.85 0.00 0.00 0.00 0.00 0.00 0.00 21,612.87
4518 BC PATIENT FEMALE 45 64,074.13 66,932.17 71,769.05 80,660.43 79,674.01 83,116.55 0.00 0.00 0.00 0.00 0.00 0.00 446,226.34
4519 BC PATIENT FEMALE 65 0.00 0.00 0.00 0.00 0.00 411.72 0.00 0.00 0.00 0.00 0.00 0.00 411.72
451G BC PATIENT FEMALE 21 0.00 229.30 391.98 140.17 1,054.27 417.43 0.00 0.00 0.00 0.00 0.00 0.00 2,233.15
451H BC PATIENT FEMALE 45 2,696.12 2,469.65 5,063.74 3,343.25 2,787.37 4,576.97 0.00 0.00 0.00 0.00 0.00 0.00 20,937.10
4617 CC PATIENT FEMALE 21 2,311.42 2,311.42 2,514.19 2,997.19 3,239.67 3,933.78 0.00 0.00 0.00 0.00 0.00 0.00 17,307.67
4618 CC PATIENT FEMALE 45 5,869.63 6,234.76 6,500.92 7,408.66 7,008.42 7,398.29 0.00 0.00 0.00 0.00 0.00 0.00 40,420.68
461G CC PATIENT FEMALE 21 0.00 0.00 364.02 620.18 432.41 748.47 0.00 0.00 0.00 0.00 0.00 0.00 2,165.08
461H CC PATIENT FEMALE 45 0.00 283.58 452.64 337.00 529.69 600.22 0.00 0.00 0.00 0.00 0.00 0.00 2,203.13
SUBTOTAL: 78,638.63 81,939.52 90,346.15 98,929.93 98,218.23 105,445.28 0.00 0.00 0.00 0.00 0.00 0.00 553,517.74
8600 SSI BLIND FREEDOM/WO 162.06 162.06 162.06 173.68 173.68 173.68 0.00 0.00 0.00 0.00 0.00 0.00 1,007.22
8700 SSI DISABLED FREEDOM 168,352.24 168,660.16 168,276.17 178,885.20 176,585.57 174,041.93 0.00 0.00 0.00 0.00 0.00 0.00 1,034,801.27
870Z SSI DISABLED FREEDOM 5,449.65 2,441.25 4,189.98 4,234.71 2,389.96 2,974.87 0.00 0.00 0.00 0.00 0.00 0.00 21,680.42
8710 SSI DISABLED FREEDOM 147,930.07 148,608.25 139,185.70 141,394.72 141,275.84 140,177.77 0.00 0.00 0.00 0.00 0.00 0.00 858,572.35
871Z SSI DISABLED FREEDOM 14,731.60 6,195.43 10,798.40 20,192.51 16,401.10 10,324.64 0.00 0.00 0.00 0.00 0.00 0.00 78,643.68
8720 SSI DISABLED FREEDOM 22,377.66 22,024.84 22,018.55 21,366.57 20,960.85 22,469.84 0.00 0.00 0.00 0.00 0.00 0.00 131,218.31
872Z SSI DISABLED FREEDOM 1,274.50 1,139.34 487.12 239.06 792.66 136.83 0.00 0.00 0.00 0.00 0.00 0.00 4,069.51
SUBTOTAL: 360,277.78 349,231.33 345,117.98 366,486.45 358,579.66 350,299.56 0.00 0.00 0.00 0.00 0.00 0.00 2,129,992.76
TOTAL: 264,329,946.27 266,996,035.62 260,594,961.24 267,996,580.35 264,035,540.20 262,879,980.26 0.00 0.00 0.00 0.00 0.00 0.00 1,586,833,043.94
16
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
ACUTE CAPITATION - MEMBER MONTHS
1002 TANF 01-05 M & F WIT 0.00 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 5.00
1003 TANF 06-13 M & F WIT 1.00 1.00 1.00 1.00 2.06 1.00 0.00 0.00 0.00 0.00 0.00 0.00 7.06
1004 TANF 14-20 MALE WITH 0.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 3.00
1005 TANF 14-20 FEMALE WI 1.00 4.00 4.00 5.00 4.00 3.00 0.00 0.00 0.00 0.00 0.00 0.00 21.00
1006 TANF 21-44 MALE WITH 116.06 101.28 104.20 115.47 114.82 119.28 0.00 0.00 0.00 0.00 0.00 0.00 671.11
1007 TANF 21-44 FEMALE WI 325.12 308.88 307.56 300.07 280.23 277.92 0.00 0.00 0.00 0.00 0.00 0.00 1,799.78
1008 TANF 45-64 M & F WIT 180.02 167.96 172.91 169.25 164.53 171.78 0.00 0.00 0.00 0.00 0.00 0.00 1,026.45
1009 TANF 65+ M & F WITH 38.94 34.87 35.56 41.87 43.82 44.87 0.00 0.00 0.00 0.00 0.00 0.00 239.93
100C TANF 06-13 M & F WIT 0.00 0.00 0.00 0.00 0.93 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.93
100F TANF 21-44 MALE WITH 1.89 1.66 7.31 1.32 1.16 1.70 0.00 0.00 0.00 0.00 0.00 0.00 15.04
100G TANF 21-44 FEMALE WI 12.64 7.12 6.35 2.87 11.78 9.62 0.00 0.00 0.00 0.00 0.00 0.00 50.38
100H TANF 44-64 M & F WIT 6.97 5.96 0.66 1.72 3.41 1.18 0.00 0.00 0.00 0.00 0.00 0.00 19.90
100J TANF 65+ M & F WITH 2.03 0.12 0.43 2.12 3.15 0.12 0.00 0.00 0.00 0.00 0.00 0.00 7.97
1011 TANF <1 M & F NON-ME 14,983.54 15,160.33 15,036.59 15,166.12 14,976.65 15,020.02 0.00 0.00 0.00 0.00 0.00 0.00 90,343.25
1012 TANF 01-05 M & F NON 88,434.87 89,049.72 88,102.92 87,516.72 86,701.90 86,131.65 0.00 0.00 0.00 0.00 0.00 0.00 525,937.78
1013 TANF 06-13 M & F NON 120,735.06 122,389.08 122,321.85 122,167.63 121,853.17 121,966.00 0.00 0.00 0.00 0.00 0.00 0.00 731,432.79
1014 TANF 14-20 MALE NON- 23,455.19 23,763.25 23,819.50 23,919.97 23,976.85 24,145.28 0.00 0.00 0.00 0.00 0.00 0.00 143,080.04
1015 TANF 14-20 FEMALE NO 29,152.23 29,477.86 29,416.24 29,537.89 29,504.07 29,657.31 0.00 0.00 0.00 0.00 0.00 0.00 176,745.60
1016 TANF 21-44 MALE NON- 21,655.48 21,936.03 21,839.58 21,738.89 21,447.09 21,313.33 0.00 0.00 0.00 0.00 0.00 0.00 129,930.40
1017 TANF 21-44 FEMALE NO 85,706.64 87,043.05 86,796.69 86,652.52 86,195.90 85,833.10 0.00 0.00 0.00 0.00 0.00 0.00 518,227.90
1018 TANF 45-64 M & F NON 16,448.32 16,693.92 16,655.11 16,574.48 16,534.31 16,569.57 0.00 0.00 0.00 0.00 0.00 0.00 99,475.71
1019 TANF 65+ M & F NON-M 48.61 54.72 47.73 50.41 43.00 38.74 0.00 0.00 0.00 0.00 0.00 0.00 283.21
101A TANF < 1 M & F NON-M 389.94 472.92 367.81 389.20 360.59 410.46 0.00 0.00 0.00 0.00 0.00 0.00 2,390.92
101B TANF 01-05 M & F NON 3,490.70 3,962.18 2,993.33 3,225.09 3,385.20 3,446.06 0.00 0.00 0.00 0.00 0.00 0.00 20,502.56
101C TANF 06-13 M & F NON 3,630.67 4,303.62 3,235.95 3,410.93 3,597.44 3,569.61 0.00 0.00 0.00 0.00 0.00 0.00 21,748.22
101D TANF 14-20 MALE NON- 789.44 988.14 664.47 700.31 724.55 810.90 0.00 0.00 0.00 0.00 0.00 0.00 4,677.81
101E TANF 14-20 FEMALE NO 1,104.13 1,332.55 997.08 1,094.58 1,008.58 1,083.52 0.00 0.00 0.00 0.00 0.00 0.00 6,620.44
101F TANF 21-44 MALE NON- 1,145.14 1,259.35 947.88 1,012.57 997.85 1,136.45 0.00 0.00 0.00 0.00 0.00 0.00 6,499.24
101G TANF 21-44 FEMALE NO 3,658.18 4,134.55 3,095.91 3,226.89 3,332.02 3,493.99 0.00 0.00 0.00 0.00 0.00 0.00 20,941.54
101H TANF 44-64 M & F NON 590.95 709.37 433.47 487.93 502.07 567.63 0.00 0.00 0.00 0.00 0.00 0.00 3,291.42
101J TANF 65+ N & F NON-M 1.44 6.05 2.12 3.56 0.00 0.12 0.00 0.00 0.00 0.00 0.00 0.00 13.29
1026 TANF 21-44 MALE WITH 3.00 3.00 5.00 5.00 2.00 2.64 0.00 0.00 0.00 0.00 0.00 0.00 20.64
1027 TANF 21-44 FEMALE WI 9.38 7.00 8.03 7.00 8.00 7.00 0.00 0.00 0.00 0.00 0.00 0.00 46.41
1028 TANF 45-64 M & F WIT 7.00 8.00 9.00 7.00 7.00 8.00 0.00 0.00 0.00 0.00 0.00 0.00 46.00
1029 TANF 65+ M & F WITH 0.00 0.00 0.00 0.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 2.00
102F TANF 21-44 MALE WITH 0.00 0.00 0.00 0.00 0.00 0.35 0.00 0.00 0.00 0.00 0.00 0.00 0.35
102G TANF 21-44 FEMALE WI 0.61 0.00 0.80 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1.41
2100 SSI AGED WITH MEDICA 3,814.65 3,772.57 3,720.42 3,766.47 3,794.26 3,822.44 0.00 0.00 0.00 0.00 0.00 0.00 22,690.81
17
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
ACUTE CAPITATION - MEMBER MONTHS
210Z SSI AGED WITH MEDICA 414.42 336.26 182.83 193.13 181.27 237.80 0.00 0.00 0.00 0.00 0.00 0.00 1,545.71
2110 SSI AGED NON-MEDICAR 5,152.65 5,118.28 5,103.31 5,066.87 5,049.22 5,006.86 0.00 0.00 0.00 0.00 0.00 0.00 30,497.19
211Z SSI AGED NON-MEDICAR 237.21 257.60 216.35 235.41 229.41 241.13 0.00 0.00 0.00 0.00 0.00 0.00 1,417.11
2120 SSI AGED WITH QMB 18,475.56 18,650.64 18,679.26 18,713.42 18,647.54 18,636.67 0.00 0.00 0.00 0.00 0.00 0.00 111,803.09
212Z SSI AGED WITH QMB PP 113.93 112.45 77.12 95.04 85.03 94.29 0.00 0.00 0.00 0.00 0.00 0.00 577.86
2200 SSI DISABLED WITH ME 3,257.52 3,281.85 3,281.54 3,357.42 3,366.66 3,441.21 0.00 0.00 0.00 0.00 0.00 0.00 19,986.20
220Z SSI DISABLED WITH ME 505.92 444.68 292.72 341.66 249.81 301.42 0.00 0.00 0.00 0.00 0.00 0.00 2,136.21
2210 SSI DISABLED NON-MED 54,957.00 55,212.04 55,517.56 55,955.25 56,125.40 56,379.05 0.00 0.00 0.00 0.00 0.00 0.00 334,146.30
221Z SSI DISABLED NON-MED 2,687.23 2,770.41 2,707.00 2,440.59 2,408.48 2,517.28 0.00 0.00 0.00 0.00 0.00 0.00 15,530.99
2220 SSI DISABLED WITH QM 24,787.12 25,011.13 25,193.27 25,288.04 25,443.51 25,562.58 0.00 0.00 0.00 0.00 0.00 0.00 151,285.65
222Z SSI DISABLED WITH QM 34.79 55.90 44.58 27.49 19.71 40.25 0.00 0.00 0.00 0.00 0.00 0.00 222.72
2300 SSI BLIND WITH MEDIC 18.00 18.25 18.83 18.93 19.60 19.87 0.00 0.00 0.00 0.00 0.00 0.00 113.48
230Z SSI BLIND WITH MEDIC 0.00 7.73 0.16 0.00 0.00 1.12 0.00 0.00 0.00 0.00 0.00 0.00 9.01
2310 SSI BLIND NON-MEDICA 389.19 390.85 397.58 397.22 393.42 398.82 0.00 0.00 0.00 0.00 0.00 0.00 2,367.08
231Z SSI BLIND NON-MEDICA 25.76 12.42 2.39 2.92 15.27 16.52 0.00 0.00 0.00 0.00 0.00 0.00 75.28
2320 SSI BLIND WITH QMB 202.83 201.93 200.64 207.00 205.90 206.12 0.00 0.00 0.00 0.00 0.00 0.00 1,224.42
232Z SSI BLIND WITH QMB P 0.00 0.06 0.33 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.39
4303 SOBRA CHILD 06-13 M 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 3.00
4304 SOBRA CHILD 14-20 MA 1.00 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 6.00
4305 SOBRA CHILD 14-20 FE 0.00 0.00 0.00 1.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 5.00
4311 SOBRA CHILD <1 M & F 32,495.25 32,689.55 32,376.91 33,075.97 32,805.17 32,854.07 0.00 0.00 0.00 0.00 0.00 0.00 196,296.92
4312 SOBRA CHILD 01-05 M 96,862.43 97,742.91 96,293.73 95,575.09 94,275.69 93,514.62 0.00 0.00 0.00 0.00 0.00 0.00 574,264.47
4313 SOBRA CHILD 06-13 M 117,841.23 119,196.55 118,355.24 118,062.42 117,438.12 116,888.48 0.00 0.00 0.00 0.00 0.00 0.00 707,782.04
4314 SOBRA CHILD 14-20 MA 30,352.47 30,711.51 30,393.88 30,075.62 29,822.85 29,595.57 0.00 0.00 0.00 0.00 0.00 0.00 180,951.90
4315 SOBRA CHILD 14-20 FE 29,683.83 30,137.42 29,834.51 29,631.83 29,385.58 29,137.69 0.00 0.00 0.00 0.00 0.00 0.00 177,810.86
431A SOBRA CHILD < 1 M & 611.20 771.58 547.03 563.97 579.43 587.61 0.00 0.00 0.00 0.00 0.00 0.00 3,660.82
431B SOBRA CHILD 01-05 M 4,719.41 5,249.11 3,577.30 3,965.19 4,360.04 4,408.17 0.00 0.00 0.00 0.00 0.00 0.00 26,279.22
431C SOBRA CHILD 6-13 M&F 4,491.81 5,191.36 3,593.19 3,870.96 3,955.43 3,970.88 0.00 0.00 0.00 0.00 0.00 0.00 25,073.63
431D SOBRA CHILD 14-20 MA 1,273.33 1,548.03 1,119.93 1,176.87 1,149.57 1,088.13 0.00 0.00 0.00 0.00 0.00 0.00 7,355.86
431E SOBRA CHILD 14-20 FE 1,319.53 1,608.71 1,077.59 1,143.63 1,145.81 1,106.42 0.00 0.00 0.00 0.00 0.00 0.00 7,401.69
5007 SOBRA PREG 21-44 FEM 59.89 64.74 61.29 62.79 57.75 62.70 0.00 0.00 0.00 0.00 0.00 0.00 369.16
5008 SOBRA PREG 45-64 FEM 0.00 0.00 0.00 0.00 2.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 3.00
500G SOBRA PREG 21-44 FEM 2.08 6.81 0.66 6.12 6.22 2.27 0.00 0.00 0.00 0.00 0.00 0.00 24.16
5013 SOBRA PREG 09-13 FEM 1.12 1.95 1.00 1.45 1.00 0.35 0.00 0.00 0.00 0.00 0.00 0.00 6.87
5015 SOBRA PREG 14-20 FEM 3,925.41 4,094.50 3,942.48 3,892.13 3,711.70 3,539.18 0.00 0.00 0.00 0.00 0.00 0.00 23,105.40
5017 SOBRA PREG 21-44 FEM 11,169.36 11,548.35 11,463.59 11,388.01 11,038.04 10,653.54 0.00 0.00 0.00 0.00 0.00 0.00 67,260.89
5018 SOBRA PREG 45-64 FEM 17.81 21.46 23.40 25.93 19.82 20.53 0.00 0.00 0.00 0.00 0.00 0.00 128.95
501C SOBRA PREG 09-13 FEM 0.87 0.03 0.00 0.54 0.00 1.64 0.00 0.00 0.00 0.00 0.00 0.00 3.08
18
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
ACUTE CAPITATION - MEMBER MONTHS
501E SOBRA PREG 14-20 FEM 519.26 576.32 428.79 414.59 426.98 453.35 0.00 0.00 0.00 0.00 0.00 0.00 2,819.29
501G SOBRA PREG 21-44 FEM 1,549.14 1,677.87 1,212.73 1,219.43 1,247.65 1,357.69 0.00 0.00 0.00 0.00 0.00 0.00 8,264.51
501H SOBRA PREG 45-64 FEM 4.14 6.10 1.60 0.06 2.16 4.44 0.00 0.00 0.00 0.00 0.00 0.00 18.50
5027 SOBRA PREG 21-44 FEM 3.00 1.74 2.00 0.00 0.00 1.67 0.00 0.00 0.00 0.00 0.00 0.00 8.41
502G SOBRA PREG 21-44 FEM 0.00 0.25 0.00 0.00 0.00 0.32 0.00 0.00 0.00 0.00 0.00 0.00 0.57
5500 SOBRA FPS FEMALE WIT 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2.00
5510 SOBRA FPS FEMALE WIT 3,934.86 3,916.00 4,075.98 3,984.08 4,149.44 4,278.27 0.00 0.00 0.00 0.00 0.00 0.00 24,338.63
872,040.40 885,810.44 SUBTOTAL: 871,459.76 871,782.92 867,608.07 866,299.22 0.00 0.00 0.00 0.00 0.00 0.00 5,235,000.81
9910 TANF & SOBRA CHILDRE 1,036.00 1,180.00 1,013.00 1,101.00 1,018.00 1,010.00 0.00 0.00 0.00 0.00 0.00 0.00 6,358.00
9920 SSI W/MEDICARE KICK 10.00 11.00 8.00 9.00 8.00 12.00 0.00 0.00 0.00 0.00 0.00 0.00 58.00
9921 SSI W/O MEDICARE KIC 41.00 23.00 33.00 55.00 43.00 40.00 0.00 0.00 0.00 0.00 0.00 0.00 235.00
9950 S.O.B.R.A. KICK PAYM 1,914.00 2,048.00 1,957.00 2,063.00 1,843.00 1,872.00 0.00 0.00 0.00 0.00 0.00 0.00 11,697.00
SUBTOTAL: 3,001.00 3,262.00 3,011.00 3,228.00 2,912.00 2,934.00 0.00 0.00 0.00 0.00 0.00 0.00 18,348.00
3100 TRANSPLANT OPTION 1 2.00 2.00 0.48 2.83 5.00 4.00 0.00 0.00 0.00 0.00 0.00 0.00 16.31
310Z TRANSPLANT OPTION 1 0.00 0.00 0.00 6.15 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 6.15
SUBTOTAL: 2.00 2.00 0.48 8.98 5.00 4.00 0.00 0.00 0.00 0.00 0.00 0.00 22.46
1106 TANF EXPANDED 21-44 779.83 782.94 779.79 773.20 777.72 767.74 0.00 0.00 0.00 0.00 0.00 0.00 4,661.22
1107 TANF EXPANDED 21-44 1,645.63 1,676.94 1,660.49 1,646.95 1,651.45 1,662.02 0.00 0.00 0.00 0.00 0.00 0.00 9,943.48
1108 TANF EXPANDED 45-64 2,056.13 2,118.89 2,111.49 2,109.83 2,129.86 2,125.27 0.00 0.00 0.00 0.00 0.00 0.00 12,651.47
1109 TANF EXPANDED 65+ M& 567.31 574.47 574.25 576.69 575.45 587.03 0.00 0.00 0.00 0.00 0.00 0.00 3,455.20
110F TANF EXPANDED 21-44 12.97 14.97 16.67 17.58 22.56 23.43 0.00 0.00 0.00 0.00 0.00 0.00 108.18
110G TANF EXPANDED 21-44 36.41 63.66 36.93 24.73 46.28 38.92 0.00 0.00 0.00 0.00 0.00 0.00 246.93
110H TANF EXPANDED 45-64 45.95 56.42 35.42 48.08 37.88 39.94 0.00 0.00 0.00 0.00 0.00 0.00 263.69
110J TANF EXPANDED 65+ M& 3.62 13.92 4.68 12.41 9.93 11.40 0.00 0.00 0.00 0.00 0.00 0.00 55.96
1111 TANF EXPANDED <1 M&F 33.89 29.55 30.09 29.68 25.76 25.88 0.00 0.00 0.00 0.00 0.00 0.00 174.85
1112 TANF EXPANDED 01-05 1,015.16 1,028.06 1,012.34 1,009.44 1,012.86 973.90 0.00 0.00 0.00 0.00 0.00 0.00 6,051.76
1113 TANF EXPANDED 06-13 3,527.91 3,568.22 3,609.81 3,621.41 3,638.08 3,668.29 0.00 0.00 0.00 0.00 0.00 0.00 21,633.72
1114 TANF EXPANDED 14-20 1,755.78 1,749.12 1,716.18 1,700.40 1,694.16 1,691.88 0.00 0.00 0.00 0.00 0.00 0.00 10,307.52
1115 TANF EXPANDED 14-20 3,153.92 3,207.24 3,150.07 3,103.37 3,107.01 3,078.49 0.00 0.00 0.00 0.00 0.00 0.00 18,800.10
1116 TANF EXPANDED 21-44 26,499.90 26,815.29 26,353.39 25,908.78 25,494.60 25,208.74 0.00 0.00 0.00 0.00 0.00 0.00 156,280.70
1117 TANF EXPANDED 21-44 53,965.59 54,770.40 53,939.36 53,635.10 53,279.04 53,218.95 0.00 0.00 0.00 0.00 0.00 0.00 322,808.44
1118 TANF EXPANDED 45-64 17,624.55 17,803.13 17,710.31 17,671.13 17,651.46 17,464.51 0.00 0.00 0.00 0.00 0.00 0.00 105,925.09
1119 TANF EXPANDED 65+ M& 49.23 41.77 48.01 38.32 34.23 37.72 0.00 0.00 0.00 0.00 0.00 0.00 249.28
111A TANF EXPANDED <1 M&F 7.04 5.40 0.89 1.28 2.81 2.46 0.00 0.00 0.00 0.00 0.00 0.00 19.88
111B TANF EXPANDED 01-05 63.20 50.13 32.65 51.09 31.63 53.02 0.00 0.00 0.00 0.00 0.00 0.00 281.72
111C TANF EXPANDED 06-13 178.91 176.80 109.16 132.97 119.05 106.32 0.00 0.00 0.00 0.00 0.00 0.00 823.21
111D TANF EXPANDED 14-20 110.01 125.19 98.05 81.38 99.28 97.55 0.00 0.00 0.00 0.00 0.00 0.00 611.46
19
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
ACUTE CAPITATION - MEMBER MONTHS
111E TANF EXPANDED 14-20 187.80 217.08 166.20 165.41 142.93 155.42 0.00 0.00 0.00 0.00 0.00 0.00 1,034.84
111F TANF EXPANDED 21-44 1,458.71 1,640.40 1,167.61 1,266.07 1,247.98 1,410.38 0.00 0.00 0.00 0.00 0.00 0.00 8,191.15
111G TANF EXPANDED 21-44 2,729.01 3,302.43 2,305.39 2,470.74 2,518.78 2,603.16 0.00 0.00 0.00 0.00 0.00 0.00 15,929.51
111H TANF EXPANDED 45-64 798.14 948.71 714.87 717.88 690.91 641.64 0.00 0.00 0.00 0.00 0.00 0.00 4,512.15
111J TANF EXPANDED 65+ M& 5.55 7.62 8.84 1.67 2.76 6.23 0.00 0.00 0.00 0.00 0.00 0.00 32.67
1126 TANF EXPANDED 21-44 32.19 30.70 32.40 30.90 31.00 33.77 0.00 0.00 0.00 0.00 0.00 0.00 190.96
1127 TANF EXPANDED 21-44 67.31 66.96 64.76 65.54 64.65 60.15 0.00 0.00 0.00 0.00 0.00 0.00 389.37
1128 TANF EXPANDED 45-64 117.67 123.08 122.25 117.00 113.22 118.77 0.00 0.00 0.00 0.00 0.00 0.00 711.99
1129 TANF EXPANDED 65+ M& 40.00 40.00 36.00 40.00 38.00 43.00 0.00 0.00 0.00 0.00 0.00 0.00 237.00
112F TANF EXPANDED 21-44 0.80 0.29 0.60 1.09 0.00 0.21 0.00 0.00 0.00 0.00 0.00 0.00 2.99
112G TANF EXPANDED 21-44 2.67 1.01 0.23 1.44 1.33 1.83 0.00 0.00 0.00 0.00 0.00 0.00 8.51
112H TANF EXPANDED 45-64 1.31 3.88 2.73 0.00 1.23 0.22 0.00 0.00 0.00 0.00 0.00 0.00 9.37
2400 SSI AGED EXPANDED WI 319.99 371.04 311.62 340.33 371.86 339.45 0.00 0.00 0.00 0.00 0.00 0.00 2,054.29
240Z SSI AGED EXPANDED WI 414.62 400.88 248.82 232.81 216.75 185.56 0.00 0.00 0.00 0.00 0.00 0.00 1,699.44
2410 SSI AGED EXPANDED NO 1,337.03 1,315.89 1,242.37 1,209.56 1,198.09 1,137.87 0.00 0.00 0.00 0.00 0.00 0.00 7,440.81
241Z SSI AGED EXPANDED NO 81.73 80.19 66.04 86.16 69.22 76.50 0.00 0.00 0.00 0.00 0.00 0.00 459.84
2420 SSI AGED EXPANDED WI 19,558.71 19,677.63 19,743.84 19,794.75 19,766.81 19,900.66 0.00 0.00 0.00 0.00 0.00 0.00 118,442.40
242Z SSI AGED EXPANDED WI 188.47 178.50 127.22 179.42 126.77 159.34 0.00 0.00 0.00 0.00 0.00 0.00 959.72
2520 SSI BLIND EXPANDED W 8.00 9.93 10.00 11.00 11.00 11.00 0.00 0.00 0.00 0.00 0.00 0.00 60.93
252Z SSI BLIND EXPANDED W 0.00 0.06 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.06
2600 SSI DISABLED EXPANDE 477.24 487.24 491.84 482.14 500.85 482.42 0.00 0.00 0.00 0.00 0.00 0.00 2,921.73
260Z SSI DISABLED EXPANDE 402.66 367.92 259.52 236.25 244.05 192.58 0.00 0.00 0.00 0.00 0.00 0.00 1,702.98
2610 SSI DISABLED EXPANDE 4,478.67 4,367.05 4,155.04 3,886.52 3,767.84 3,580.08 0.00 0.00 0.00 0.00 0.00 0.00 24,235.20
261Z SSI DISABLED EXPANDE 157.04 164.81 123.46 129.15 155.28 137.72 0.00 0.00 0.00 0.00 0.00 0.00 867.46
2620 SSI DISABLED EXPANDE 7,165.80 7,341.53 7,517.41 7,697.99 7,836.97 7,971.84 0.00 0.00 0.00 0.00 0.00 0.00 45,531.54
262Z SSI DISABLED EXPANDE 49.82 56.19 41.70 56.92 30.99 18.32 0.00 0.00 0.00 0.00 0.00 0.00 253.94
153,213.88 155,873.53 SUBTOTAL: 151,990.79 151,414.56 150,590.37 150,151.58 0.00 0.00 0.00 0.00 0.00 0.00 913,234.71
9911 SB PAYMENT FOR TANF 69.00 80.00 56.00 56.00 56.00 62.00 0.00 0.00 0.00 0.00 0.00 0.00 379.00
9922 SB PAYMENT FOR SSI E 2.00 2.00 1.00 0.00 2.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 8.00
9923 SB PAYMENT FOR SSI E 5.00 5.00 4.00 5.00 4.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 25.00
SUBTOTAL: 76.00 87.00 61.00 61.00 62.00 65.00 0.00 0.00 0.00 0.00 0.00 0.00 412.00
3306 AHC CARE MALE 21-44 6.00 5.00 5.00 4.00 5.00 5.00 0.00 0.00 0.00 0.00 0.00 0.00 30.00
3307 AHC CARE FEMALE 21-4 3.00 2.00 1.00 1.00 2.03 1.00 0.00 0.00 0.00 0.00 0.00 0.00 10.03
3308 AHC CARE M&F 45-64 W 13.00 14.00 13.00 13.00 13.00 12.00 0.00 0.00 0.00 0.00 0.00 0.00 78.00
3309 AHC CARE M&F 65+ W/ 9.00 10.32 10.00 11.00 11.00 10.00 0.00 0.00 0.00 0.00 0.00 0.00 61.32
330G AHC CARE FEMALE 21-4 0.00 0.00 0.00 0.00 1.96 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1.96
330J AHC CARE M&F 65+ W/ 0.00 2.67 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2.67
20
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
ACUTE CAPITATION - MEMBER MONTHS
3314 AHC CARE MALE 14-20 1,032.80 996.29 962.45 931.86 921.66 917.32 0.00 0.00 0.00 0.00 0.00 0.00 5,762.38
3315 AHC CARE FEMALE 14-2 1,283.43 1,230.38 1,213.17 1,173.16 1,195.93 1,165.75 0.00 0.00 0.00 0.00 0.00 0.00 7,261.82
3316 AHC CARE MALE 21-44 4,640.05 4,297.37 3,864.34 3,590.69 3,406.46 3,256.43 0.00 0.00 0.00 0.00 0.00 0.00 23,055.34
3317 AHC CARE FEMALE 21-4 4,793.33 4,482.29 4,044.64 3,798.41 3,628.77 3,444.88 0.00 0.00 0.00 0.00 0.00 0.00 24,192.32
3318 AHC CARE M&F 45-64 N 13,562.02 12,961.75 12,285.20 11,813.09 11,354.22 10,951.62 0.00 0.00 0.00 0.00 0.00 0.00 72,927.90
3319 AHC CARE M&F 65+ NO 0.00 0.00 0.00 0.00 0.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 1.00
331A AHC CARE M&F < 1 NO 0.00 0.00 0.00 0.33 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.33
331D AHC CARE MALE 14-20 5.16 9.02 6.08 9.08 4.26 10.93 0.00 0.00 0.00 0.00 0.00 0.00 44.53
331E AHC CARE FEMALE 14-2 9.26 13.45 13.94 10.49 6.96 5.57 0.00 0.00 0.00 0.00 0.00 0.00 59.67
331F AHC CARE MALE 21-44 28.68 21.45 11.03 20.53 12.93 8.49 0.00 0.00 0.00 0.00 0.00 0.00 103.11
331G AHC CARE FEMALE 21-4 20.38 35.89 15.22 13.90 10.25 14.03 0.00 0.00 0.00 0.00 0.00 0.00 109.67
331H AHC CARE M&F 45-64 N 57.08 54.35 35.13 57.76 19.60 24.60 0.00 0.00 0.00 0.00 0.00 0.00 248.52
331J AHC CARE M&F 65+ NO 0.00 0.00 0.00 4.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4.00
3326 AHC CARE MALE 21-44 6.00 6.00 6.00 6.00 7.00 7.00 0.00 0.00 0.00 0.00 0.00 0.00 38.00
3327 AHC CARE FEMALE 21-4 2.00 2.00 2.00 1.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 11.00
3328 AHC CARE M&F 45-64 W 12.00 12.00 16.00 17.00 18.00 17.00 0.00 0.00 0.00 0.00 0.00 0.00 92.00
3329 AHC CARE M&F 65+ W/ 2.00 -2.50 2.00 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 7.50
25,485.19 24,153.73 SUBTOTAL: 22,506.20 21,478.30 20,623.03 19,856.62 0.00 0.00 0.00 0.00 0.00 0.00 134,103.07
9933 SB PAYMENT FOR AHCCS 9.00 6.00 7.00 4.00 6.00 6.00 0.00 0.00 0.00 0.00 0.00 0.00 38.00
SUBTOTAL: 9.00 6.00 7.00 4.00 6.00 6.00 0.00 0.00 0.00 0.00 0.00 0.00 38.00
3606 AHC CARE/MI MALE 21- 6.00 8.00 5.00 7.00 7.00 7.00 0.00 0.00 0.00 0.00 0.00 0.00 40.00
3607 AHC CARE/MI FEMALE 2 2.00 2.00 1.00 1.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 10.00
3608 AHC CARE/MI M&F 45-6 8.87 8.54 7.00 10.90 11.99 12.35 0.00 0.00 0.00 0.00 0.00 0.00 59.65
360F AHC CARE/MI MALE 21- 0.00 3.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 3.00
360H AHC CARE/MI M&F 45-6 0.00 5.45 0.00 0.00 0.00 0.64 0.00 0.00 0.00 0.00 0.00 0.00 6.09
3614 AHC CARE/MI MALE 14- 7,069.28 6,898.12 6,736.61 6,642.90 6,532.41 6,426.60 0.00 0.00 0.00 0.00 0.00 0.00 40,305.92
3615 AHC CARE/MI FEMALE 1 6,395.51 6,285.14 6,082.72 5,990.76 5,913.46 5,853.52 0.00 0.00 0.00 0.00 0.00 0.00 36,521.11
3616 AHC CARE/MI MALE 21- 17,681.71 16,583.57 15,569.78 14,782.37 14,081.73 13,392.73 0.00 0.00 0.00 0.00 0.00 0.00 92,091.89
3617 AHC CARE/MI FEMALE 2 11,497.24 10,912.20 10,254.93 9,805.83 9,393.58 8,961.19 0.00 0.00 0.00 0.00 0.00 0.00 60,824.97
3618 AHC CARE/MI M&F 45-6 30,046.99 29,054.52 27,990.73 27,064.80 26,253.41 25,420.59 0.00 0.00 0.00 0.00 0.00 0.00 165,831.04
3619 AHC CARE/MI M&F 65+ 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 5.00
361D AHC CARE/MI MALE 14- 42.28 38.07 29.96 36.34 44.70 38.79 0.00 0.00 0.00 0.00 0.00 0.00 230.14
361E AHC CARE/MI FEMALE 1 39.77 63.65 35.73 39.12 25.31 48.42 0.00 0.00 0.00 0.00 0.00 0.00 252.00
361F AHC CARE/MI MALE 21- 74.26 66.42 61.46 77.13 40.56 80.07 0.00 0.00 0.00 0.00 0.00 0.00 399.90
361G AHC CARE/MI FEMALE 2 50.68 45.73 40.75 37.55 41.95 38.46 0.00 0.00 0.00 0.00 0.00 0.00 255.12
361H AHC CARE/MI M&F 45-6 103.01 98.79 79.40 100.77 63.27 87.35 0.00 0.00 0.00 0.00 0.00 0.00 532.59
361J AHC CARE/MI M&F 65+ 0.00 0.00 0.00 0.00 5.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 5.00
21
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
ACUTE CAPITATION - MEMBER MONTHS
3626 AHC CARE/MI MALE 21- 2.00 2.00 2.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 9.00
3628 AHC CARE/MI M&F 45-6 0.00 0.00 0.00 0.00 0.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 1.00
73,020.60 70,076.20 SUBTOTAL: 66,898.07 64,598.47 62,418.37 60,371.71 0.00 0.00 0.00 0.00 0.00 0.00 397,383.42
9936 SB PAYMENT FOR AHC C 26.00 27.00 20.00 15.00 22.00 21.00 0.00 0.00 0.00 0.00 0.00 0.00 131.00
SUBTOTAL: 26.00 27.00 20.00 15.00 22.00 21.00 0.00 0.00 0.00 0.00 0.00 0.00 131.00
4517 BC PATIENT FEMALE 21 17.00 15.93 14.93 15.25 15.42 18.75 0.00 0.00 0.00 0.00 0.00 0.00 97.28
4518 BC PATIENT FEMALE 45 177.54 185.10 198.58 210.34 207.73 216.39 0.00 0.00 0.00 0.00 0.00 0.00 1,195.68
4519 BC PATIENT FEMALE 65 0.00 0.00 0.00 0.00 0.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 1.00
451G BC PATIENT FEMALE 21 0.00 1.06 2.06 0.74 5.55 2.20 0.00 0.00 0.00 0.00 0.00 0.00 11.61
451H BC PATIENT FEMALE 45 9.38 8.82 16.66 10.57 8.20 14.49 0.00 0.00 0.00 0.00 0.00 0.00 68.12
4617 CC PATIENT FEMALE 21 10.00 10.00 10.99 12.93 13.73 16.37 0.00 0.00 0.00 0.00 0.00 0.00 74.02
4618 CC PATIENT FEMALE 45 16.00 16.93 17.66 18.73 17.73 18.80 0.00 0.00 0.00 0.00 0.00 0.00 105.85
461G CC PATIENT FEMALE 21 0.00 0.00 1.99 3.05 2.26 3.60 0.00 0.00 0.00 0.00 0.00 0.00 10.90
461H CC PATIENT FEMALE 45 0.00 1.06 1.33 1.25 1.26 2.19 0.00 0.00 0.00 0.00 0.00 0.00 7.09
SUBTOTAL: 229.92 238.90 264.20 272.86 271.88 293.79 0.00 0.00 0.00 0.00 0.00 0.00 1,571.55
8600 SSI BLIND FREEDOM/WO 1.00 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 6.00
8700 SSI DISABLED FREEDOM 1,199.56 1,201.86 1,198.06 1,208.57 1,193.68 1,179.65 0.00 0.00 0.00 0.00 0.00 0.00 7,181.38
870Z SSI DISABLED FREEDOM 44.79 19.98 34.85 34.53 20.21 25.21 0.00 0.00 0.00 0.00 0.00 0.00 179.57
8710 SSI DISABLED FREEDOM 204.27 205.54 192.30 189.16 189.70 187.97 0.00 0.00 0.00 0.00 0.00 0.00 1,168.94
871Z SSI DISABLED FREEDOM 42.57 18.35 33.02 58.60 47.05 29.63 0.00 0.00 0.00 0.00 0.00 0.00 229.22
8720 SSI DISABLED FREEDOM 162.27 161.41 163.00 150.06 148.26 158.80 0.00 0.00 0.00 0.00 0.00 0.00 943.80
872Z SSI DISABLED FREEDOM 10.69 9.57 4.00 1.96 6.72 1.12 0.00 0.00 0.00 0.00 0.00 0.00 34.06
SUBTOTAL: 1,665.15 1,617.71 1,626.23 1,643.88 1,606.62 1,583.38 0.00 0.00 0.00 0.00 0.00 0.00 9,742.97
TOTAL: 1,128,769.14 1,141,154.51 1,117,844.73 1,114,507.97 1,106,125.34 1,101,586.30 0.00 0.00 0.00 0.00 0.00 0.00 6,709,987.99
22
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
LONG TERM CARE CAPITATION - AMOUNTS
1000 TANF WITH MEDICARE 3,084.22 3,084.22 3,084.22 3,084.22 3,084.22 3,084.22 0.00 0.00 0.00 0.00 0.00 0.00 18,505.32
1010 TANF NON-MEDICARE 1,769,861.66 1,770,148.54 1,778,678.77 1,810,728.13 1,830,508.87 1,814,939.94 0.00 0.00 0.00 0.00 0.00 0.00 10,774,865.91
101Z TANF ALTCS NON-MEDIC 0.00 0.00 0.00 0.00 6,999.68 0.00 0.00 0.00 0.00 0.00 0.00 0.00 6,999.68
1020 TANF WITH QMB 6,168.44 6,168.44 6,168.44 6,168.44 6,168.44 6,168.44 0.00 0.00 0.00 0.00 0.00 0.00 37,010.64
2100 SSI AGED WITH MEDICA 30,902,003.43 31,049,195.48 31,067,327.90 29,061,381.86 29,247,115.25 29,032,221.04 0.00 0.00 0.00 0.00 0.00 0.00 180,359,244.96
210Z SSI AGED WITH MEDICA 649,356.96 731,494.62 577,011.84 597,387.73 572,489.16 478,182.79 0.00 0.00 0.00 0.00 0.00 0.00 3,605,923.10
2110 SSI AGED NON-MEDICAR 1,663,517.30 1,627,493.25 1,599,864.60 2,355,542.31 2,353,594.23 2,348,245.30 0.00 0.00 0.00 0.00 0.00 0.00 11,948,256.99
211Z SSI AGED NON-MEDICAR 30,085.47 10,327.64 9,798.11 29,092.86 13,352.88 11,895.76 0.00 0.00 0.00 0.00 0.00 0.00 104,552.72
2120 SSI AGED WITH QMB 17,549,222.44 17,665,857.36 17,793,672.01 16,712,978.69 16,732,292.89 16,636,365.51 0.00 0.00 0.00 0.00 0.00 0.00 103,090,388.90
212Z SSI AGED WITH QMB PP 12,965.87 11,781.47 21,566.19 22,270.18 18,723.76 11,865.22 0.00 0.00 0.00 0.00 0.00 0.00 99,172.69
2200 SSI DISABLED WITH ME 12,674,905.93 12,773,245.06 12,830,394.95 12,452,321.45 12,550,287.31 12,607,409.91 0.00 0.00 0.00 0.00 0.00 0.00 75,888,564.61
220Z SSI DISABLED WITH ME 95,331.46 92,184.90 105,975.22 75,496.78 92,285.09 59,868.85 0.00 0.00 0.00 0.00 0.00 0.00 521,142.30
2210 SSI DISABLED NON-MED 68,224,658.40 68,324,897.36 68,619,488.93 73,979,425.45 74,038,268.41 74,351,934.24 0.00 0.00 0.00 0.00 0.00 0.00 427,538,672.79
221Z SSI DISABLED NON-MED 96,149.26 95,156.37 48,488.18 85,652.38 81,919.53 78,809.75 0.00 0.00 0.00 0.00 0.00 0.00 486,175.47
2220 SSI DISABLED WITH QM 18,324,783.39 18,402,677.71 18,414,760.59 18,118,785.78 18,119,452.21 18,136,625.81 0.00 0.00 0.00 0.00 0.00 0.00 109,517,085.49
222Z SSI DISABLED WITH QM 421.48 5,806.73 3,205.16 930.99 2,478.61 1,118.49 0.00 0.00 0.00 0.00 0.00 0.00 13,961.46
2300 SSI BLIND WITH MEDIC 67,202.85 67,202.85 67,202.85 65,031.84 65,411.32 65,411.32 0.00 0.00 0.00 0.00 0.00 0.00 397,463.03
2310 SSI BLIND NON-MEDICA 359,879.83 372,864.04 299,002.60 469,230.15 396,740.03 395,373.92 0.00 0.00 0.00 0.00 0.00 0.00 2,293,090.57
2320 SSI BLIND WITH QMB 131,782.30 127,255.28 126,147.53 123,848.90 115,815.60 121,354.09 0.00 0.00 0.00 0.00 0.00 0.00 746,203.70
152,561,380.69 153,136,841.32 153,371,838.09 155,969,358.14 156,246,987.49 156,160,874.60 SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 0.00 927,447,280.33
8700 SSI DISABLED FREEDOM 64,032.51 60,222.69 63,525.01 57,366.32 57,366.32 57,366.32 0.00 0.00 0.00 0.00 0.00 0.00 359,879.17
870Z SSI DISABLED FREEDOM 0.00 29.15 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 29.15
8710 SSI DISABLED FREEDOM 51,313.37 51,602.60 51,602.60 73,752.53 78,143.37 80,976.30 0.00 0.00 0.00 0.00 0.00 0.00 387,390.77
871Z SSI DISABLED FREEDOM 2,769.50 0.00 0.00 0.00 4,600.73 2,044.31 0.00 0.00 0.00 0.00 0.00 0.00 9,414.54
8720 SSI DISABLED FREEDOM 9,243.96 9,243.96 9,243.96 12,213.87 12,213.87 12,213.87 0.00 0.00 0.00 0.00 0.00 0.00 64,373.49
SUBTOTAL: 127,359.34 121,098.40 124,371.57 143,332.72 152,324.29 152,600.80 0.00 0.00 0.00 0.00 0.00 0.00 821,087.12
TOTAL: 152,688,740.03 153,257,939.72 153,496,209.66 156,112,690.86 156,399,311.78 156,313,475.40 0.00 0.00 0.00 0.00 0.00 0.00 928,268,367.45
23
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
LONG TERM CARE MEMBER MONTHS
1000 TANF WITH MEDICARE 1.00 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 6.00
1010 TANF NON-MEDICARE 576.63 576.74 579.17 582.48 580.59 583.51 0.00 0.00 0.00 0.00 0.00 0.00 3,479.12
101Z TANF ALTCS NON-MEDIC 0.00 0.00 0.00 0.00 7.86 0.00 0.00 0.00 0.00 0.00 0.00 0.00 7.86
1020 TANF WITH QMB 2.00 2.00 2.00 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 12.00
2100 SSI AGED WITH MEDICA 11,109.53 11,152.38 11,165.71 11,203.42 11,255.76 11,161.77 0.00 0.00 0.00 0.00 0.00 0.00 67,048.57
210Z SSI AGED WITH MEDICA 712.73 803.28 634.78 663.98 645.22 553.09 0.00 0.00 0.00 0.00 0.00 0.00 4,013.08
2110 SSI AGED NON-MEDICAR 600.88 589.25 578.57 580.62 576.09 575.10 0.00 0.00 0.00 0.00 0.00 0.00 3,500.51
211Z SSI AGED NON-MEDICAR 33.24 11.26 11.06 32.17 15.40 13.49 0.00 0.00 0.00 0.00 0.00 0.00 116.62
2120 SSI AGED WITH QMB 6,810.67 6,863.41 6,898.84 6,890.34 6,893.67 6,865.38 0.00 0.00 0.00 0.00 0.00 0.00 41,222.31
212Z SSI AGED WITH QMB PP 14.20 12.47 23.85 24.41 21.59 14.36 0.00 0.00 0.00 0.00 0.00 0.00 110.88
2200 SSI DISABLED WITH ME 4,346.80 4,380.57 4,391.80 4,420.69 4,456.91 4,476.45 0.00 0.00 0.00 0.00 0.00 0.00 26,473.22
220Z SSI DISABLED WITH ME 104.54 100.97 117.06 84.58 104.38 69.49 0.00 0.00 0.00 0.00 0.00 0.00 581.02
2210 SSI DISABLED NON-MED 22,790.91 22,793.11 22,847.84 22,982.09 23,003.72 23,122.24 0.00 0.00 0.00 0.00 0.00 0.00 137,539.91
221Z SSI DISABLED NON-MED 106.01 104.61 52.45 93.80 94.48 89.80 0.00 0.00 0.00 0.00 0.00 0.00 541.15
2220 SSI DISABLED WITH QM 6,235.35 6,267.85 6,278.34 6,326.34 6,325.12 6,328.23 0.00 0.00 0.00 0.00 0.00 0.00 37,761.23
222Z SSI DISABLED WITH QM 0.47 6.41 3.75 1.03 2.93 1.22 0.00 0.00 0.00 0.00 0.00 0.00 15.81
2300 SSI BLIND WITH MEDIC 22.00 22.00 22.00 23.00 24.00 24.00 0.00 0.00 0.00 0.00 0.00 0.00 137.00
2310 SSI BLIND NON-MEDICA 120.00 125.00 100.56 146.68 124.23 124.22 0.00 0.00 0.00 0.00 0.00 0.00 740.69
2320 SSI BLIND WITH QMB 48.93 47.45 48.00 48.00 46.00 47.00 0.00 0.00 0.00 0.00 0.00 0.00 285.38
53,635.89 53,859.76 SUBTOTAL: 53,756.78 54,106.63 54,180.95 54,052.35 0.00 0.00 0.00 0.00 0.00 0.00 323,592.36
8700 SSI DISABLED FREEDOM 21.03 19.97 21.00 20.00 20.00 20.00 0.00 0.00 0.00 0.00 0.00 0.00 122.00
870Z SSI DISABLED FREEDOM 0.00 0.03 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.03
8710 SSI DISABLED FREEDOM 17.93 18.00 18.00 17.99 18.96 19.58 0.00 0.00 0.00 0.00 0.00 0.00 110.46
871Z SSI DISABLED FREEDOM 3.06 0.00 0.00 0.00 5.16 2.41 0.00 0.00 0.00 0.00 0.00 0.00 10.63
8720 SSI DISABLED FREEDOM 3.00 3.00 3.00 4.00 4.00 4.00 0.00 0.00 0.00 0.00 0.00 0.00 21.00
SUBTOTAL: 45.02 41.00 42.00 41.99 48.12 45.99 0.00 0.00 0.00 0.00 0.00 0.00 264.12
TOTAL: 53,680.91 53,900.76 53,798.78 54,148.62 54,229.07 54,098.34 0.00 0.00 0.00 0.00 0.00 0.00 323,856.48
24
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN
1000 TANF WITH MEDICARE 38.41 115.23 115.23 115.23 76.82 76.82 0.00 0.00 0.00 0.00 0.00 0.00 537.74
1010 TANF NON-MEDICARE 10,828,047.87 10,870,337.28 10,926,108.60 10,870,030.00 10,779,267.17 10,736,555.25 0.00 0.00 0.00 0.00 0.00 0.00 65,010,346.17
2110 SSI AGED NON-MEDICAR 38.41 38.41 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 76.82
2120 SSI AGED WITH QMB 38.41 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 38.41
2200 SSI DISABLED WITH ME 192.05 0.00 38.41 38.41 38.41 38.41 0.00 0.00 0.00 0.00 0.00 0.00 345.69
2210 SSI DISABLED NON-MED 592,896.76 592,896.76 593,127.22 590,284.88 587,250.49 587,711.41 0.00 0.00 0.00 0.00 0.00 0.00 3,544,167.52
2220 SSI DISABLED WITH QM 537.74 691.38 691.38 691.38 691.38 652.97 0.00 0.00 0.00 0.00 0.00 0.00 3,956.23
2310 SSI BLIND NON-MEDICA 2,343.01 2,266.19 2,343.01 2,419.83 2,458.24 2,535.06 0.00 0.00 0.00 0.00 0.00 0.00 14,365.34
4300 SOBRA CHILD WITH MED 76.82 76.82 76.82 76.82 76.82 76.82 0.00 0.00 0.00 0.00 0.00 0.00 460.92
4310 SOBRA CHILD NON-MEDI 10,989,331.46 11,034,501.62 11,037,420.78 10,960,908.06 10,845,678.06 10,790,866.99 0.00 0.00 0.00 0.00 0.00 0.00 65,658,706.97
5010 SOBRA PREGNANT WOMAN 20,895.04 21,010.27 21,010.27 20,050.02 19,051.36 16,938.81 0.00 0.00 0.00 0.00 0.00 0.00 118,955.77
22,434,435.98 22,521,933.96 22,580,931.72 22,444,614.63 SUBTOTAL: 22,234,588.75 22,135,452.54 0.00 0.00 0.00 0.00 0.00 0.00 134,351,957.58
1110 TANF EXPANDED FOR FI 265,451.51 266,911.09 269,369.33 267,448.83 269,561.38 269,945.48 0.00 0.00 0.00 0.00 0.00 0.00 1,608,687.62
2610 SSI DISABLED EXPANDE 38.41 38.41 76.82 153.64 192.05 192.05 0.00 0.00 0.00 0.00 0.00 0.00 691.38
SUBTOTAL: 265,489.92 266,949.50 269,446.15 267,602.47 269,753.43 270,137.53 0.00 0.00 0.00 0.00 0.00 0.00 1,609,379.00
TOTAL: 22,699,925.90 22,788,883.46 22,850,377.87 22,712,217.10 22,504,342.18 22,405,590.07 0.00 0.00 0.00 0.00 0.00 0.00 135,961,336.58
25
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN
1000 TANF WITH MEDICARE 1.00 3.00 3.00 3.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 14.00
1010 TANF NON-MEDICARE 281,907.00 283,008.00 284,460.00 283,000.00 280,637.00 279,525.00 0.00 0.00 0.00 0.00 0.00 0.00 1,692,537.00
2110 SSI AGED NON-MEDICAR 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2.00
2120 SSI AGED WITH QMB 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1.00
2200 SSI DISABLED WITH ME 5.00 0.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 9.00
2210 SSI DISABLED NON-MED 15,436.00 15,436.00 15,442.00 15,368.00 15,289.00 15,301.00 0.00 0.00 0.00 0.00 0.00 0.00 92,272.00
2220 SSI DISABLED WITH QM 14.00 18.00 18.00 18.00 18.00 17.00 0.00 0.00 0.00 0.00 0.00 0.00 103.00
2310 SSI BLIND NON-MEDICA 61.00 59.00 61.00 63.00 64.00 66.00 0.00 0.00 0.00 0.00 0.00 0.00 374.00
4300 SOBRA CHILD WITH MED 2.00 2.00 2.00 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 12.00
4310 SOBRA CHILD NON-MEDI 286,106.00 287,282.00 287,358.00 285,366.00 282,366.00 280,939.00 0.00 0.00 0.00 0.00 0.00 0.00 1,709,417.00
5010 SOBRA PREGNANT WOMAN 544.00 547.00 547.00 522.00 496.00 441.00 0.00 0.00 0.00 0.00 0.00 0.00 3,097.00
584,078.00 586,356.00 SUBTOTAL: 587,892.00 584,343.00 578,875.00 576,294.00 0.00 0.00 0.00 0.00 0.00 0.00 3,497,838.00
1110 TANF EXPANDED FOR FI 6,911.00 6,949.00 7,013.00 6,963.00 7,018.00 7,028.00 0.00 0.00 0.00 0.00 0.00 0.00 41,882.00
2610 SSI DISABLED EXPANDE 1.00 1.00 2.00 4.00 5.00 5.00 0.00 0.00 0.00 0.00 0.00 0.00 18.00
SUBTOTAL: 6,912.00 6,950.00 7,015.00 6,967.00 7,023.00 7,033.00 0.00 0.00 0.00 0.00 0.00 0.00 41,900.00
TOTAL: 590,990.00 593,306.00 594,907.00 591,310.00 585,898.00 583,327.00 0.00 0.00 0.00 0.00 0.00 0.00 3,539,738.00
26
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
MENTAL HEALTH CAPITATION AMOUNTS - ADULT
1000 TANF WITH MEDICARE 53,444.24 49,022.32 49,556.00 50,928.32 48,641.12 48,946.08 0.00 0.00 0.00 0.00 0.00 0.00 300,538.08
1010 TANF NON-MEDICARE 10,862,446.48 10,936,475.52 11,015,002.72 10,988,394.96 10,903,006.16 10,846,664.80 0.00 0.00 0.00 0.00 0.00 0.00 65,551,990.64
1020 TANF WITH QMB 1,524.80 1,448.56 1,753.52 1,448.56 1,372.32 1,372.32 0.00 0.00 0.00 0.00 0.00 0.00 8,920.08
2100 SSI AGED WITH MEDICA 312,202.80 306,256.08 307,704.64 309,229.44 312,431.52 312,355.28 0.00 0.00 0.00 0.00 0.00 0.00 1,860,179.76
2110 SSI AGED NON-MEDICAR 397,744.08 390,730.00 391,416.16 387,604.16 385,469.44 383,029.76 0.00 0.00 0.00 0.00 0.00 0.00 2,335,993.60
2120 SSI AGED WITH QMB 1,535,473.60 1,546,070.96 1,550,721.60 1,552,627.60 1,549,120.56 1,544,393.68 0.00 0.00 0.00 0.00 0.00 0.00 9,278,408.00
2200 SSI DISABLED WITH ME 305,341.20 305,569.92 307,628.40 311,974.08 313,803.84 317,997.04 0.00 0.00 0.00 0.00 0.00 0.00 1,862,314.48
2210 SSI DISABLED NON-MED 3,423,557.20 3,437,585.36 3,468,157.60 3,504,981.52 3,528,692.16 3,545,617.44 0.00 0.00 0.00 0.00 0.00 0.00 20,908,591.28
2220 SSI DISABLED WITH QM 2,106,206.24 2,125,190.00 2,138,608.24 2,147,833.28 2,161,251.52 2,166,435.84 0.00 0.00 0.00 0.00 0.00 0.00 12,845,525.12
2300 SSI BLIND WITH MEDIC 2,058.48 1,982.24 2,058.48 2,134.72 2,134.72 2,134.72 0.00 0.00 0.00 0.00 0.00 0.00 12,503.36
2310 SSI BLIND NON-MEDICA 29,581.12 29,886.08 30,419.76 30,343.52 29,962.32 30,267.28 0.00 0.00 0.00 0.00 0.00 0.00 180,460.08
2320 SSI BLIND WITH QMB 18,755.04 18,526.32 18,678.80 19,060.00 18,907.52 18,983.76 0.00 0.00 0.00 0.00 0.00 0.00 112,911.44
4300 SOBRA CHILD WITH MED 0.00 0.00 0.00 0.00 76.24 76.24 0.00 0.00 0.00 0.00 0.00 0.00 152.48
4310 SOBRA CHILD NON-MEDI 1,444,214.32 1,435,522.96 1,422,409.68 1,372,015.04 1,332,751.44 1,300,425.68 0.00 0.00 0.00 0.00 0.00 0.00 8,307,339.12
5000 SOBRA PREGNANT WOMAN 4,421.92 4,574.40 4,955.60 4,498.16 4,574.40 4,803.12 0.00 0.00 0.00 0.00 0.00 0.00 27,827.60
5010 SOBRA PREGNANT WOMAN 1,091,604.32 1,115,238.72 1,133,078.88 1,113,637.68 1,074,907.76 1,030,459.84 0.00 0.00 0.00 0.00 0.00 0.00 6,558,927.20
5020 SOBRA PREGNANT WOMAN 228.72 76.24 152.48 0.00 0.00 76.24 0.00 0.00 0.00 0.00 0.00 0.00 533.68
21,588,804.56 21,704,155.68 21,842,302.56 21,796,711.04 SUBTOTAL: 21,667,103.04 21,554,039.12 0.00 0.00 0.00 0.00 0.00 0.00 130,153,116.00
1100 TANF EXPANDED FPR FI 398,049.04 402,699.68 404,758.16 402,775.92 404,072.00 403,767.04 0.00 0.00 0.00 0.00 0.00 0.00 2,416,121.84
1110 TANF EXPANDED FOR FI 7,910,052.48 7,940,014.80 7,928,731.28 7,833,812.48 7,744,840.40 7,682,781.04 0.00 0.00 0.00 0.00 0.00 0.00 47,040,232.48
1120 TANF EXPANDED FOR FI 20,661.04 20,508.56 20,127.36 20,203.60 19,746.16 20,356.08 0.00 0.00 0.00 0.00 0.00 0.00 121,602.80
2400 SSI AGED EXPANDED WI 19,822.40 22,795.76 20,966.00 22,262.08 25,464.16 23,329.44 0.00 0.00 0.00 0.00 0.00 0.00 134,639.84
2410 SSI AGED EXPANDED NO 102,237.84 100,331.84 96,062.40 92,555.36 92,174.16 86,761.12 0.00 0.00 0.00 0.00 0.00 0.00 570,122.72
2420 SSI AGED EXPANDED WI 1,568,714.24 1,572,602.48 1,583,809.76 1,587,545.52 1,585,868.24 1,593,111.04 0.00 0.00 0.00 0.00 0.00 0.00 9,491,651.28
2520 SSI BLIND EXPANDED W 686.16 762.40 838.64 914.88 914.88 914.88 0.00 0.00 0.00 0.00 0.00 0.00 5,031.84
2600 SSI DISABLED EXPANDE 32,249.52 33,164.40 34,536.72 33,469.36 34,231.76 34,841.68 0.00 0.00 0.00 0.00 0.00 0.00 202,493.44
2610 SSI DISABLED EXPANDE 357,565.60 347,501.92 331,796.48 307,552.16 297,793.44 284,603.92 0.00 0.00 0.00 0.00 0.00 0.00 1,926,813.52
2620 SSI DISABLED EXPANDE 569,055.36 581,482.48 596,959.20 611,444.80 622,652.08 634,011.84 0.00 0.00 0.00 0.00 0.00 0.00 3,615,605.76
SUBTOTAL: 10,979,093.68 11,021,864.32 11,018,586.00 10,912,536.16 10,827,757.28 10,764,478.08 0.00 0.00 0.00 0.00 0.00 0.00 65,524,315.52
3300 AHC CARE EXPANDED FO 2,515.92 2,515.92 2,287.20 2,287.20 2,363.44 2,287.20 0.00 0.00 0.00 0.00 0.00 0.00 14,256.88
3310 AHC CARE EXPANDED FO 2,011,668.64 1,903,331.60 1,774,562.24 1,690,622.00 1,625,055.60 1,561,776.40 0.00 0.00 0.00 0.00 0.00 0.00 10,567,016.48
3320 AHC CARE EXPANDED FO 1,753.52 1,829.76 2,134.72 2,134.72 2,363.44 2,287.20 0.00 0.00 0.00 0.00 0.00 0.00 12,503.36
SUBTOTAL: 2,015,938.08 1,907,677.28 1,778,984.16 1,695,043.92 1,629,782.48 1,566,350.80 0.00 0.00 0.00 0.00 0.00 0.00 10,593,776.72
3600 AHC CARE EXPANDED FO 1,524.80 1,601.04 1,143.60 1,448.56 1,677.28 1,677.28 0.00 0.00 0.00 0.00 0.00 0.00 9,072.56
3610 AHC CARE EXPANDED FO 6,362,075.52 6,102,859.52 5,841,432.56 5,632,916.16 5,446,890.56 5,253,393.44 0.00 0.00 0.00 0.00 0.00 0.00 34,639,567.76
3620 AHC CARE EXPANDED FO 152.48 152.48 152.48 76.24 76.24 152.48 0.00 0.00 0.00 0.00 0.00 0.00 762.40
27
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
MENTAL HEALTH CAPITATION AMOUNTS - ADULT
6,363,752.80 6,104,613.04 SUBTOTAL: 5,842,728.64 5,634,440.96 5,448,644.08 5,255,223.20 0.00 0.00 0.00 0.00 0.00 0.00 34,649,402.72
4510 BC PATIENT FOR FINAN 14,561.84 15,095.52 15,781.68 16,849.04 16,239.12 17,077.76 0.00 0.00 0.00 0.00 0.00 0.00 95,604.96
4610 CC PATIENT FOR FINAN 2,058.48 2,058.48 2,134.72 2,363.44 2,287.20 2,515.92 0.00 0.00 0.00 0.00 0.00 0.00 13,418.24
SUBTOTAL: 16,620.32 17,154.00 17,916.40 19,212.48 18,526.32 19,593.68 0.00 0.00 0.00 0.00 0.00 0.00 109,023.20
8600 SSI BLIND FREEDOM/WO 76.24 76.24 76.24 76.24 76.24 76.24 0.00 0.00 0.00 0.00 0.00 0.00 457.44
8700 SSI DISABLED FREEDOM 91,488.00 91,030.56 90,954.32 92,021.68 90,344.40 90,039.44 0.00 0.00 0.00 0.00 0.00 0.00 545,878.40
8710 SSI DISABLED FREEDOM 14,943.04 15,019.28 14,333.12 13,951.92 13,875.68 13,875.68 0.00 0.00 0.00 0.00 0.00 0.00 85,998.72
8720 SSI DISABLED FREEDOM 12,274.64 12,427.12 12,579.60 11,740.96 11,512.24 12,045.92 0.00 0.00 0.00 0.00 0.00 0.00 72,580.48
SUBTOTAL: 118,781.92 118,553.20 117,943.28 117,790.80 115,808.56 116,037.28 0.00 0.00 0.00 0.00 0.00 0.00 704,915.04
TOTAL: 41,082,991.36 40,874,017.52 40,618,461.04 40,175,735.36 39,707,621.76 39,275,722.16 0.00 0.00 0.00 0.00 0.00 0.00 241,734,549.20
28
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
1000 TANF WITH MEDICARE 701.00 643.00 650.00 668.00 638.00 642.00 0.00 0.00 0.00 0.00 0.00 0.00 3,942.00
1010 TANF NON-MEDICARE 142,477.00 143,448.00 144,478.00 144,129.00 143,009.00 142,270.00 0.00 0.00 0.00 0.00 0.00 0.00 859,811.00
1020 TANF WITH QMB 20.00 19.00 23.00 19.00 18.00 18.00 0.00 0.00 0.00 0.00 0.00 0.00 117.00
2100 SSI AGED WITH MEDICA 4,095.00 4,017.00 4,036.00 4,056.00 4,098.00 4,097.00 0.00 0.00 0.00 0.00 0.00 0.00 24,399.00
2110 SSI AGED NON-MEDICAR 5,217.00 5,125.00 5,134.00 5,084.00 5,056.00 5,024.00 0.00 0.00 0.00 0.00 0.00 0.00 30,640.00
2120 SSI AGED WITH QMB 20,140.00 20,279.00 20,340.00 20,365.00 20,319.00 20,257.00 0.00 0.00 0.00 0.00 0.00 0.00 121,700.00
2200 SSI DISABLED WITH ME 4,005.00 4,008.00 4,035.00 4,092.00 4,116.00 4,171.00 0.00 0.00 0.00 0.00 0.00 0.00 24,427.00
2210 SSI DISABLED NON-MED 44,905.00 45,089.00 45,490.00 45,973.00 46,284.00 46,506.00 0.00 0.00 0.00 0.00 0.00 0.00 274,247.00
2220 SSI DISABLED WITH QM 27,626.00 27,875.00 28,051.00 28,172.00 28,348.00 28,416.00 0.00 0.00 0.00 0.00 0.00 0.00 168,488.00
2300 SSI BLIND WITH MEDIC 27.00 26.00 27.00 28.00 28.00 28.00 0.00 0.00 0.00 0.00 0.00 0.00 164.00
2310 SSI BLIND NON-MEDICA 388.00 392.00 399.00 398.00 393.00 397.00 0.00 0.00 0.00 0.00 0.00 0.00 2,367.00
2320 SSI BLIND WITH QMB 246.00 243.00 245.00 250.00 248.00 249.00 0.00 0.00 0.00 0.00 0.00 0.00 1,481.00
4300 SOBRA CHILD WITH MED 0.00 0.00 0.00 0.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 2.00
4310 SOBRA CHILD NON-MEDI 18,943.00 18,829.00 18,657.00 17,996.00 17,481.00 17,057.00 0.00 0.00 0.00 0.00 0.00 0.00 108,963.00
5000 SOBRA PREGNANT WOMAN 58.00 60.00 65.00 59.00 60.00 63.00 0.00 0.00 0.00 0.00 0.00 0.00 365.00
5010 SOBRA PREGNANT WOMAN 14,318.00 14,628.00 14,862.00 14,607.00 14,099.00 13,516.00 0.00 0.00 0.00 0.00 0.00 0.00 86,030.00
5020 SOBRA PREGNANT WOMAN 3.00 1.00 2.00 0.00 0.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 7.00
283,169.00 284,682.00 SUBTOTAL: 286,494.00 285,896.00 284,196.00 282,713.00 0.00 0.00 0.00 0.00 0.00 0.00 1,707,150.00
1100 TANF EXPANDED FPR FI 5,221.00 5,282.00 5,309.00 5,283.00 5,300.00 5,296.00 0.00 0.00 0.00 0.00 0.00 0.00 31,691.00
1110 TANF EXPANDED FOR FI 103,752.00 104,145.00 103,997.00 102,752.00 101,585.00 100,771.00 0.00 0.00 0.00 0.00 0.00 0.00 617,002.00
1120 TANF EXPANDED FOR FI 271.00 269.00 264.00 265.00 259.00 267.00 0.00 0.00 0.00 0.00 0.00 0.00 1,595.00
2400 SSI AGED EXPANDED WI 260.00 299.00 275.00 292.00 334.00 306.00 0.00 0.00 0.00 0.00 0.00 0.00 1,766.00
2410 SSI AGED EXPANDED NO 1,341.00 1,316.00 1,260.00 1,214.00 1,209.00 1,138.00 0.00 0.00 0.00 0.00 0.00 0.00 7,478.00
2420 SSI AGED EXPANDED WI 20,576.00 20,627.00 20,774.00 20,823.00 20,801.00 20,896.00 0.00 0.00 0.00 0.00 0.00 0.00 124,497.00
2520 SSI BLIND EXPANDED W 9.00 10.00 11.00 12.00 12.00 12.00 0.00 0.00 0.00 0.00 0.00 0.00 66.00
2600 SSI DISABLED EXPANDE 423.00 435.00 453.00 439.00 449.00 457.00 0.00 0.00 0.00 0.00 0.00 0.00 2,656.00
2610 SSI DISABLED EXPANDE 4,690.00 4,558.00 4,352.00 4,034.00 3,906.00 3,733.00 0.00 0.00 0.00 0.00 0.00 0.00 25,273.00
2620 SSI DISABLED EXPANDE 7,464.00 7,627.00 7,830.00 8,020.00 8,167.00 8,316.00 0.00 0.00 0.00 0.00 0.00 0.00 47,424.00
SUBTOTAL: 144,007.00 144,568.00 144,525.00 143,134.00 142,022.00 141,192.00 0.00 0.00 0.00 0.00 0.00 0.00 859,448.00
3300 AHC CARE EXPANDED FO 33.00 33.00 30.00 30.00 31.00 30.00 0.00 0.00 0.00 0.00 0.00 0.00 187.00
3310 AHC CARE EXPANDED FO 26,386.00 24,965.00 23,276.00 22,175.00 21,315.00 20,485.00 0.00 0.00 0.00 0.00 0.00 0.00 138,602.00
3320 AHC CARE EXPANDED FO 23.00 24.00 28.00 28.00 31.00 30.00 0.00 0.00 0.00 0.00 0.00 0.00 164.00
SUBTOTAL: 26,442.00 25,022.00 23,334.00 22,233.00 21,377.00 20,545.00 0.00 0.00 0.00 0.00 0.00 0.00 138,953.00
3600 AHC CARE EXPANDED FO 20.00 21.00 15.00 19.00 22.00 22.00 0.00 0.00 0.00 0.00 0.00 0.00 119.00
3610 AHC CARE EXPANDED FO 83,448.00 80,048.00 76,619.00 73,884.00 71,444.00 68,906.00 0.00 0.00 0.00 0.00 0.00 0.00 454,349.00
3620 AHC CARE EXPANDED FO 2.00 2.00 2.00 1.00 1.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 10.00
29
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT
83,470.00 80,071.00 SUBTOTAL: 76,636.00 73,904.00 71,467.00 68,930.00 0.00 0.00 0.00 0.00 0.00 0.00 454,478.00
4510 BC PATIENT FOR FINAN 191.00 198.00 207.00 221.00 213.00 224.00 0.00 0.00 0.00 0.00 0.00 0.00 1,254.00
4610 CC PATIENT FOR FINAN 27.00 27.00 28.00 31.00 30.00 33.00 0.00 0.00 0.00 0.00 0.00 0.00 176.00
SUBTOTAL: 218.00 225.00 235.00 252.00 243.00 257.00 0.00 0.00 0.00 0.00 0.00 0.00 1,430.00
8600 SSI BLIND FREEDOM/WO 1.00 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 6.00
8700 SSI DISABLED FREEDOM 1,200.00 1,194.00 1,193.00 1,207.00 1,185.00 1,181.00 0.00 0.00 0.00 0.00 0.00 0.00 7,160.00
8710 SSI DISABLED FREEDOM 196.00 197.00 188.00 183.00 182.00 182.00 0.00 0.00 0.00 0.00 0.00 0.00 1,128.00
8720 SSI DISABLED FREEDOM 161.00 163.00 165.00 154.00 151.00 158.00 0.00 0.00 0.00 0.00 0.00 0.00 952.00
SUBTOTAL: 1,558.00 1,555.00 1,547.00 1,545.00 1,519.00 1,522.00 0.00 0.00 0.00 0.00 0.00 0.00 9,246.00
TOTAL: 538,864.00 536,123.00 532,771.00 526,964.00 520,824.00 515,159.00 0.00 0.00 0.00 0.00 0.00 0.00 3,170,705.00
30
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
1000 TANF WITH MEDICARE 30,346.29 27,835.47 28,138.50 28,917.72 27,619.02 27,792.18 0.00 0.00 0.00 0.00 0.00 0.00 170,649.18
1010 TANF NON-MEDICARE 6,167,829.33 6,209,863.92 6,254,452.62 6,239,344.41 6,190,859.61 6,158,868.30 0.00 0.00 0.00 0.00 0.00 0.00 37,221,218.19
1020 TANF WITH QMB 865.80 822.51 995.67 822.51 779.22 779.22 0.00 0.00 0.00 0.00 0.00 0.00 5,064.93
2100 SSI AGED WITH MEDICA 177,272.55 173,895.93 174,718.44 175,584.24 177,402.42 177,359.13 0.00 0.00 0.00 0.00 0.00 0.00 1,056,232.71
2110 SSI AGED NON-MEDICAR 225,843.93 221,861.25 222,250.86 220,086.36 218,874.24 217,488.96 0.00 0.00 0.00 0.00 0.00 0.00 1,326,405.60
2120 SSI AGED WITH QMB 871,860.60 877,877.91 880,518.60 881,600.85 879,609.51 876,925.53 0.00 0.00 0.00 0.00 0.00 0.00 5,268,393.00
2200 SSI DISABLED WITH ME 173,376.45 173,506.32 174,675.15 177,142.68 178,181.64 180,562.59 0.00 0.00 0.00 0.00 0.00 0.00 1,057,444.83
2210 SSI DISABLED NON-MED 1,943,937.45 1,951,902.81 1,969,262.10 1,990,171.17 2,003,634.36 2,013,244.74 0.00 0.00 0.00 0.00 0.00 0.00 11,872,152.63
2220 SSI DISABLED WITH QM 1,195,929.54 1,206,708.75 1,214,327.79 1,219,565.88 1,227,184.92 1,230,128.64 0.00 0.00 0.00 0.00 0.00 0.00 7,293,845.52
2300 SSI BLIND WITH MEDIC 1,168.83 1,125.54 1,168.83 1,212.12 1,212.12 1,212.12 0.00 0.00 0.00 0.00 0.00 0.00 7,099.56
2310 SSI BLIND NON-MEDICA 16,796.52 16,969.68 17,272.71 17,229.42 17,012.97 17,186.13 0.00 0.00 0.00 0.00 0.00 0.00 102,467.43
2320 SSI BLIND WITH QMB 10,649.34 10,519.47 10,606.05 10,822.50 10,735.92 10,779.21 0.00 0.00 0.00 0.00 0.00 0.00 64,112.49
4300 SOBRA CHILD WITH MED 0.00 0.00 0.00 0.00 43.29 43.29 0.00 0.00 0.00 0.00 0.00 0.00 86.58
4310 SOBRA CHILD NON-MEDI 820,042.47 815,107.41 807,661.53 779,046.84 756,752.49 738,397.53 0.00 0.00 0.00 0.00 0.00 0.00 4,717,008.27
5000 SOBRA PREGNANT WOMAN 2,510.82 2,597.40 2,813.85 2,554.11 2,597.40 2,727.27 0.00 0.00 0.00 0.00 0.00 0.00 15,800.85
5010 SOBRA PREGNANT WOMAN 619,826.22 633,246.12 643,375.98 632,337.03 610,345.71 585,107.64 0.00 0.00 0.00 0.00 0.00 0.00 3,724,238.70
5020 SOBRA PREGNANT WOMAN 129.87 43.29 86.58 0.00 0.00 43.29 0.00 0.00 0.00 0.00 0.00 0.00 303.03
12,258,386.01 12,323,883.78 12,402,325.26 12,376,437.84 SUBTOTAL: 12,302,844.84 12,238,645.77 0.00 0.00 0.00 0.00 0.00 0.00 73,902,523.50
1100 TANF EXPANDED FPR FI 226,017.09 228,657.78 229,826.61 228,701.07 229,437.00 229,263.84 0.00 0.00 0.00 0.00 0.00 0.00 1,371,903.39
1110 TANF EXPANDED FOR FI 4,491,424.08 4,508,437.05 4,502,030.13 4,448,134.08 4,397,614.65 4,362,376.59 0.00 0.00 0.00 0.00 0.00 0.00 26,710,016.58
1120 TANF EXPANDED FOR FI 11,731.59 11,645.01 11,428.56 11,471.85 11,212.11 11,558.43 0.00 0.00 0.00 0.00 0.00 0.00 69,047.55
2400 SSI AGED EXPANDED WI 11,255.40 12,943.71 11,904.75 12,640.68 14,458.86 13,246.74 0.00 0.00 0.00 0.00 0.00 0.00 76,450.14
2410 SSI AGED EXPANDED NO 58,051.89 56,969.64 54,545.40 52,554.06 52,337.61 49,264.02 0.00 0.00 0.00 0.00 0.00 0.00 323,722.62
2420 SSI AGED EXPANDED WI 890,735.04 892,942.83 899,306.46 901,427.67 900,475.29 904,587.84 0.00 0.00 0.00 0.00 0.00 0.00 5,389,475.13
2520 SSI BLIND EXPANDED W 389.61 432.90 476.19 519.48 519.48 519.48 0.00 0.00 0.00 0.00 0.00 0.00 2,857.14
2600 SSI DISABLED EXPANDE 18,311.67 18,831.15 19,610.37 19,004.31 19,437.21 19,783.53 0.00 0.00 0.00 0.00 0.00 0.00 114,978.24
2610 SSI DISABLED EXPANDE 203,030.10 197,315.82 188,398.08 174,631.86 169,090.74 161,601.57 0.00 0.00 0.00 0.00 0.00 0.00 1,094,068.17
2620 SSI DISABLED EXPANDE 323,116.56 330,172.83 338,960.70 347,185.80 353,549.43 359,999.64 0.00 0.00 0.00 0.00 0.00 0.00 2,052,984.96
SUBTOTAL: 6,234,063.03 6,258,348.72 6,256,487.25 6,196,270.86 6,148,132.38 6,112,201.68 0.00 0.00 0.00 0.00 0.00 0.00 37,205,503.92
3300 AHC CARE EXPANDED FO 1,428.57 1,428.57 1,298.70 1,298.70 1,341.99 1,298.70 0.00 0.00 0.00 0.00 0.00 0.00 8,095.23
3310 AHC CARE EXPANDED FO 1,142,249.94 1,080,734.85 1,007,618.04 959,955.75 922,726.35 886,795.65 0.00 0.00 0.00 0.00 0.00 0.00 6,000,080.58
3320 AHC CARE EXPANDED FO 995.67 1,038.96 1,212.12 1,212.12 1,341.99 1,298.70 0.00 0.00 0.00 0.00 0.00 0.00 7,099.56
SUBTOTAL: 1,144,674.18 1,083,202.38 1,010,128.86 962,466.57 925,410.33 889,393.05 0.00 0.00 0.00 0.00 0.00 0.00 6,015,275.37
3600 AHC CARE EXPANDED FO 865.80 909.09 649.35 822.51 952.38 952.38 0.00 0.00 0.00 0.00 0.00 0.00 5,151.51
3610 AHC CARE EXPANDED FO 3,612,463.92 3,465,277.92 3,316,836.51 3,198,438.36 3,092,810.76 2,982,940.74 0.00 0.00 0.00 0.00 0.00 0.00 19,668,768.21
3620 AHC CARE EXPANDED FO 86.58 86.58 86.58 43.29 43.29 86.58 0.00 0.00 0.00 0.00 0.00 0.00 432.90
31
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
MENTAL HEALTH CAPITATION AMOUNTS - GENERAL
3,613,416.30 3,466,273.59 SUBTOTAL: 3,317,572.44 3,199,304.16 3,093,806.43 2,983,979.70 0.00 0.00 0.00 0.00 0.00 0.00 19,674,352.62
4510 BC PATIENT FOR FINAN 8,268.39 8,571.42 8,961.03 9,567.09 9,220.77 9,696.96 0.00 0.00 0.00 0.00 0.00 0.00 54,285.66
4610 CC PATIENT FOR FINAN 1,168.83 1,168.83 1,212.12 1,341.99 1,298.70 1,428.57 0.00 0.00 0.00 0.00 0.00 0.00 7,619.04
SUBTOTAL: 9,437.22 9,740.25 10,173.15 10,909.08 10,519.47 11,125.53 0.00 0.00 0.00 0.00 0.00 0.00 61,904.70
8600 SSI BLIND FREEDOM/WO 43.29 43.29 43.29 43.29 43.29 43.29 0.00 0.00 0.00 0.00 0.00 0.00 259.74
8700 SSI DISABLED FREEDOM 51,948.00 51,688.26 51,644.97 52,251.03 51,298.65 51,125.49 0.00 0.00 0.00 0.00 0.00 0.00 309,956.40
8710 SSI DISABLED FREEDOM 8,484.84 8,528.13 8,138.52 7,922.07 7,878.78 7,878.78 0.00 0.00 0.00 0.00 0.00 0.00 48,831.12
8720 SSI DISABLED FREEDOM 6,969.69 7,056.27 7,142.85 6,666.66 6,536.79 6,839.82 0.00 0.00 0.00 0.00 0.00 0.00 41,212.08
SUBTOTAL: 67,445.82 67,315.95 66,969.63 66,883.05 65,757.51 65,887.38 0.00 0.00 0.00 0.00 0.00 0.00 400,259.34
TOTAL: 23,327,422.56 23,208,764.67 23,063,656.59 22,812,271.56 22,546,470.96 22,301,233.11 0.00 0.00 0.00 0.00 0.00 0.00 137,259,819.45
32
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
1000 TANF WITH MEDICARE 701.00 643.00 650.00 668.00 638.00 642.00 0.00 0.00 0.00 0.00 0.00 0.00 3,942.00
1010 TANF NON-MEDICARE 142,477.00 143,448.00 144,478.00 144,129.00 143,009.00 142,270.00 0.00 0.00 0.00 0.00 0.00 0.00 859,811.00
1020 TANF WITH QMB 20.00 19.00 23.00 19.00 18.00 18.00 0.00 0.00 0.00 0.00 0.00 0.00 117.00
2100 SSI AGED WITH MEDICA 4,095.00 4,017.00 4,036.00 4,056.00 4,098.00 4,097.00 0.00 0.00 0.00 0.00 0.00 0.00 24,399.00
2110 SSI AGED NON-MEDICAR 5,217.00 5,125.00 5,134.00 5,084.00 5,056.00 5,024.00 0.00 0.00 0.00 0.00 0.00 0.00 30,640.00
2120 SSI AGED WITH QMB 20,140.00 20,279.00 20,340.00 20,365.00 20,319.00 20,257.00 0.00 0.00 0.00 0.00 0.00 0.00 121,700.00
2200 SSI DISABLED WITH ME 4,005.00 4,008.00 4,035.00 4,092.00 4,116.00 4,171.00 0.00 0.00 0.00 0.00 0.00 0.00 24,427.00
2210 SSI DISABLED NON-MED 44,905.00 45,089.00 45,490.00 45,973.00 46,284.00 46,506.00 0.00 0.00 0.00 0.00 0.00 0.00 274,247.00
2220 SSI DISABLED WITH QM 27,626.00 27,875.00 28,051.00 28,172.00 28,348.00 28,416.00 0.00 0.00 0.00 0.00 0.00 0.00 168,488.00
2300 SSI BLIND WITH MEDIC 27.00 26.00 27.00 28.00 28.00 28.00 0.00 0.00 0.00 0.00 0.00 0.00 164.00
2310 SSI BLIND NON-MEDICA 388.00 392.00 399.00 398.00 393.00 397.00 0.00 0.00 0.00 0.00 0.00 0.00 2,367.00
2320 SSI BLIND WITH QMB 246.00 243.00 245.00 250.00 248.00 249.00 0.00 0.00 0.00 0.00 0.00 0.00 1,481.00
4300 SOBRA CHILD WITH MED 0.00 0.00 0.00 0.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 2.00
4310 SOBRA CHILD NON-MEDI 18,943.00 18,829.00 18,657.00 17,996.00 17,481.00 17,057.00 0.00 0.00 0.00 0.00 0.00 0.00 108,963.00
5000 SOBRA PREGNANT WOMAN 58.00 60.00 65.00 59.00 60.00 63.00 0.00 0.00 0.00 0.00 0.00 0.00 365.00
5010 SOBRA PREGNANT WOMAN 14,318.00 14,628.00 14,862.00 14,607.00 14,099.00 13,516.00 0.00 0.00 0.00 0.00 0.00 0.00 86,030.00
5020 SOBRA PREGNANT WOMAN 3.00 1.00 2.00 0.00 0.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 7.00
283,169.00 284,682.00 SUBTOTAL: 286,494.00 285,896.00 284,196.00 282,713.00 0.00 0.00 0.00 0.00 0.00 0.00 1,707,150.00
1100 TANF EXPANDED FPR FI 5,221.00 5,282.00 5,309.00 5,283.00 5,300.00 5,296.00 0.00 0.00 0.00 0.00 0.00 0.00 31,691.00
1110 TANF EXPANDED FOR FI 103,752.00 104,145.00 103,997.00 102,752.00 101,585.00 100,771.00 0.00 0.00 0.00 0.00 0.00 0.00 617,002.00
1120 TANF EXPANDED FOR FI 271.00 269.00 264.00 265.00 259.00 267.00 0.00 0.00 0.00 0.00 0.00 0.00 1,595.00
2400 SSI AGED EXPANDED WI 260.00 299.00 275.00 292.00 334.00 306.00 0.00 0.00 0.00 0.00 0.00 0.00 1,766.00
2410 SSI AGED EXPANDED NO 1,341.00 1,316.00 1,260.00 1,214.00 1,209.00 1,138.00 0.00 0.00 0.00 0.00 0.00 0.00 7,478.00
2420 SSI AGED EXPANDED WI 20,576.00 20,627.00 20,774.00 20,823.00 20,801.00 20,896.00 0.00 0.00 0.00 0.00 0.00 0.00 124,497.00
2520 SSI BLIND EXPANDED W 9.00 10.00 11.00 12.00 12.00 12.00 0.00 0.00 0.00 0.00 0.00 0.00 66.00
2600 SSI DISABLED EXPANDE 423.00 435.00 453.00 439.00 449.00 457.00 0.00 0.00 0.00 0.00 0.00 0.00 2,656.00
2610 SSI DISABLED EXPANDE 4,690.00 4,558.00 4,352.00 4,034.00 3,906.00 3,733.00 0.00 0.00 0.00 0.00 0.00 0.00 25,273.00
2620 SSI DISABLED EXPANDE 7,464.00 7,627.00 7,830.00 8,020.00 8,167.00 8,316.00 0.00 0.00 0.00 0.00 0.00 0.00 47,424.00
SUBTOTAL: 144,007.00 144,568.00 144,525.00 143,134.00 142,022.00 141,192.00 0.00 0.00 0.00 0.00 0.00 0.00 859,448.00
3300 AHC CARE EXPANDED FO 33.00 33.00 30.00 30.00 31.00 30.00 0.00 0.00 0.00 0.00 0.00 0.00 187.00
3310 AHC CARE EXPANDED FO 26,386.00 24,965.00 23,276.00 22,175.00 21,315.00 20,485.00 0.00 0.00 0.00 0.00 0.00 0.00 138,602.00
3320 AHC CARE EXPANDED FO 23.00 24.00 28.00 28.00 31.00 30.00 0.00 0.00 0.00 0.00 0.00 0.00 164.00
SUBTOTAL: 26,442.00 25,022.00 23,334.00 22,233.00 21,377.00 20,545.00 0.00 0.00 0.00 0.00 0.00 0.00 138,953.00
3600 AHC CARE EXPANDED FO 20.00 21.00 15.00 19.00 22.00 22.00 0.00 0.00 0.00 0.00 0.00 0.00 119.00
3610 AHC CARE EXPANDED FO 83,448.00 80,048.00 76,619.00 73,884.00 71,444.00 68,906.00 0.00 0.00 0.00 0.00 0.00 0.00 454,349.00
3620 AHC CARE EXPANDED FO 2.00 2.00 2.00 1.00 1.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 10.00
33
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL
83,470.00 80,071.00 SUBTOTAL: 76,636.00 73,904.00 71,467.00 68,930.00 0.00 0.00 0.00 0.00 0.00 0.00 454,478.00
4510 BC PATIENT FOR FINAN 191.00 198.00 207.00 221.00 213.00 224.00 0.00 0.00 0.00 0.00 0.00 0.00 1,254.00
4610 CC PATIENT FOR FINAN 27.00 27.00 28.00 31.00 30.00 33.00 0.00 0.00 0.00 0.00 0.00 0.00 176.00
SUBTOTAL: 218.00 225.00 235.00 252.00 243.00 257.00 0.00 0.00 0.00 0.00 0.00 0.00 1,430.00
8600 SSI BLIND FREEDOM/WO 1.00 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 6.00
8700 SSI DISABLED FREEDOM 1,200.00 1,194.00 1,193.00 1,207.00 1,185.00 1,181.00 0.00 0.00 0.00 0.00 0.00 0.00 7,160.00
8710 SSI DISABLED FREEDOM 196.00 197.00 188.00 183.00 182.00 182.00 0.00 0.00 0.00 0.00 0.00 0.00 1,128.00
8720 SSI DISABLED FREEDOM 161.00 163.00 165.00 154.00 151.00 158.00 0.00 0.00 0.00 0.00 0.00 0.00 952.00
SUBTOTAL: 1,558.00 1,555.00 1,547.00 1,545.00 1,519.00 1,522.00 0.00 0.00 0.00 0.00 0.00 0.00 9,246.00
TOTAL: 538,864.00 536,123.00 532,771.00 526,964.00 520,824.00 515,159.00 0.00 0.00 0.00 0.00 0.00 0.00 3,170,705.00
34
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
MENTAL HEALTH CAPITATION AMOUNTS - CMDP
1010 TANF NON-MEDICARE 3,344,289.47 3,357,786.19 3,345,253.53 3,448,406.90 3,477,328.40 3,383,815.52 0.00 0.00 0.00 0.00 0.00 0.00 20,356,880.01
2210 SSI DISABLED NON-MED 335,489.45 344,165.92 327,777.03 330,669.15 341,273.70 350,914.21 0.00 0.00 0.00 0.00 0.00 0.00 2,030,289.46
2220 SSI DISABLED WITH QM 964.05 1,928.11 1,928.11 964.05 964.05 964.05 0.00 0.00 0.00 0.00 0.00 0.00 7,712.42
2310 SSI BLIND NON-MEDICA 1,928.10 2,892.15 2,892.15 2,892.15 964.05 1,928.10 0.00 0.00 0.00 0.00 0.00 0.00 13,496.70
4310 SOBRA CHILD NON-MEDI 7,849,295.14 8,068,134.49 8,232,023.06 8,533,770.62 8,608,966.54 8,555,943.78 0.00 0.00 0.00 0.00 0.00 0.00 49,848,133.63
5010 SOBRA PREGNANT WOMAN 27,957.45 23,137.20 21,209.10 25,065.30 26,993.41 23,137.20 0.00 0.00 0.00 0.00 0.00 0.00 147,499.66
11,559,923.66 11,798,044.06 11,931,082.98 12,341,768.17 SUBTOTAL: 12,456,490.15 12,316,702.86 0.00 0.00 0.00 0.00 0.00 0.00 72,404,011.88
1110 TANF EXPANDED FOR FI 964.06 0.00 0.00 0.00 964.06 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,928.12
SUBTOTAL: 964.06 0.00 0.00 0.00 964.06 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,928.12
TOTAL: 11,560,887.72 11,798,044.06 11,931,082.98 12,341,768.17 12,457,454.21 12,316,702.86 0.00 0.00 0.00 0.00 0.00 0.00 72,405,940.00
35
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP
1010 TANF NON-MEDICARE 3,471.00 3,487.00 3,473.00 3,582.00 3,612.00 3,512.00 0.00 0.00 0.00 0.00 0.00 0.00 21,137.00
2210 SSI DISABLED NON-MED 353.00 364.00 343.00 343.00 354.00 365.00 0.00 0.00 0.00 0.00 0.00 0.00 2,122.00
2220 SSI DISABLED WITH QM 1.00 3.00 3.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 10.00
2310 SSI BLIND NON-MEDICA 2.00 3.00 3.00 3.00 1.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 14.00
4310 SOBRA CHILD NON-MEDI 8,146.00 8,373.00 8,550.00 8,854.00 8,934.00 8,878.00 0.00 0.00 0.00 0.00 0.00 0.00 51,735.00
5010 SOBRA PREGNANT WOMAN 29.00 24.00 22.00 26.00 29.00 24.00 0.00 0.00 0.00 0.00 0.00 0.00 154.00
SUBTOTAL: 12,002.00 12,254.00 12,394.00 12,809.00 12,931.00 12,782.00 0.00 0.00 0.00 0.00 0.00 0.00 75,172.00
1110 TANF EXPANDED FOR FI 2.00 0.00 0.00 0.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4.00
SUBTOTAL: 2.00 0.00 0.00 0.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4.00
TOTAL: 12,004.00 12,254.00 12,394.00 12,809.00 12,933.00 12,782.00 0.00 0.00 0.00 0.00 0.00 0.00 75,176.00
36
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
1000 TANF WITH MEDICARE 42.41 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 42.41
1005 TANF 14-20 FEMALE WI 0.00 848.20 848.20 848.20 739.22 369.61 0.00 0.00 0.00 0.00 0.00 0.00 3,653.43
1010 TANF NON-MEDICARE 106,420.83 104,342.28 101,852.40 78,995.70 106,910.63 88,213.11 0.00 0.00 0.00 0.00 0.00 0.00 586,734.95
1011 TANF <1 M & F NON-ME 101,781.73 106,654.31 104,561.22 0.00 201,062.06 87,698.85 0.00 0.00 0.00 0.00 0.00 0.00 601,758.17
1012 TANF 01-05 M & F NON 884,329.67 879,221.79 897,669.20 454,889.65 1,166,495.80 745,080.59 0.00 0.00 0.00 0.00 0.00 0.00 5,027,686.70
1013 TANF 06-13 M & F NON 1,109,912.09 1,120,617.18 1,120,720.29 858,830.78 1,282,877.54 1,005,425.46 0.00 0.00 0.00 0.00 0.00 0.00 6,498,383.34
1014 TANF 14-20 MALE NON- 233,594.28 230,860.90 231,353.40 158,669.95 275,037.04 202,712.16 0.00 0.00 0.00 0.00 0.00 0.00 1,332,227.73
1015 TANF 14-20 FEMALE NO 287,949.31 278,346.41 287,430.35 203,681.55 340,212.19 263,188.19 0.00 0.00 0.00 0.00 0.00 0.00 1,660,808.00
1017 TANF 21-44 FEMALE NO 424.10 424.10 424.10 424.10 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,696.40
2200 SSI DISABLED WITH ME 6,785.60 11,505.42 6,785.60 2,544.60 4,598.79 3,326.49 0.00 0.00 0.00 0.00 0.00 0.00 35,546.50
2210 SSI DISABLED NON-MED 4,313,384.69 4,309,511.72 4,297,695.35 3,427,101.49 4,655,227.99 3,752,969.32 0.00 0.00 0.00 0.00 0.00 0.00 24,755,890.56
2220 SSI DISABLED WITH QM 13,387.42 13,174.92 18,468.87 18,632.13 20,810.49 16,854.22 0.00 0.00 0.00 0.00 0.00 0.00 101,328.05
2300 SSI BLIND WITH MEDIC 424.10 424.10 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 848.20
2310 SSI BLIND NON-MEDICA 39,865.40 36,896.70 37,320.80 28,838.80 42,799.66 35,042.33 0.00 0.00 0.00 0.00 0.00 0.00 220,763.69
2320 SSI BLIND WITH QMB 0.00 0.00 424.10 424.10 369.61 369.61 0.00 0.00 0.00 0.00 0.00 0.00 1,587.42
4303 SOBRA CHILD 06-13 M 424.10 424.10 424.10 0.00 424.10 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,696.40
4304 SOBRA CHILD 14-20 MA 424.10 424.10 424.10 424.10 369.61 369.61 0.00 0.00 0.00 0.00 0.00 0.00 2,435.62
4305 SOBRA CHILD 14-20 FE 0.00 0.00 0.00 0.00 369.61 739.22 0.00 0.00 0.00 0.00 0.00 0.00 1,108.83
4311 SOBRA CHILD <1 M & F 223,165.30 214,399.41 221,699.86 0.00 408,108.51 191,832.42 0.00 0.00 0.00 0.00 0.00 0.00 1,259,205.50
4312 SOBRA CHILD 01-05 M 992,520.78 983,569.97 966,223.37 514,291.93 1,232,642.26 822,448.27 0.00 0.00 0.00 0.00 0.00 0.00 5,511,696.58
4313 SOBRA CHILD 06-13 M 1,121,568.01 1,130,196.87 1,131,608.25 872,260.61 1,225,754.80 982,433.75 0.00 0.00 0.00 0.00 0.00 0.00 6,463,822.29
4314 SOBRA CHILD 14-20 MA 259,478.52 267,224.04 271,478.73 191,636.65 300,274.20 235,503.78 0.00 0.00 0.00 0.00 0.00 0.00 1,525,595.92
4315 SOBRA CHILD 14-20 FE 303,782.82 307,226.25 313,875.05 199,411.82 388,112.25 283,521.62 0.00 0.00 0.00 0.00 0.00 0.00 1,795,929.81
5015 SOBRA PREG 14-20 FEM 16,539.90 16,936.64 14,528.85 10,545.95 16,885.58 13,959.94 0.00 0.00 0.00 0.00 0.00 0.00 89,396.86
10,016,205.16 10,013,229.41 SUBTOTAL: 10,025,816.19 7,022,452.11 11,670,081.94 8,732,058.55 0.00 0.00 0.00 0.00 0.00 0.00 57,479,843.36
1111 TANF EXPANDED <1 M&F 848.20 848.20 424.10 0.00 793.71 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2,914.21
1112 TANF EXPANDED 01-05 9,871.29 9,330.20 11,026.60 3,816.90 15,264.46 6,968.10 0.00 0.00 0.00 0.00 0.00 0.00 56,277.55
1113 TANF EXPANDED 06-13 41,434.57 40,713.60 39,468.66 33,503.90 46,093.64 37,330.61 0.00 0.00 0.00 0.00 0.00 0.00 238,544.98
1114 TANF EXPANDED 14-20 15,267.60 17,853.24 16,539.90 11,026.60 17,068.37 11,827.52 0.00 0.00 0.00 0.00 0.00 0.00 89,583.23
1115 TANF EXPANDED 14-20 24,852.26 21,205.00 24,570.44 19,847.88 28,279.17 21,078.19 0.00 0.00 0.00 0.00 0.00 0.00 139,832.94
2410 SSI AGED EXPANDED NO 424.10 0.00 0.00 0.00 369.61 369.61 0.00 0.00 0.00 0.00 0.00 0.00 1,163.32
2420 SSI AGED EXPANDED WI 0.00 848.20 848.20 0.00 793.71 369.61 0.00 0.00 0.00 0.00 0.00 0.00 2,859.72
2600 SSI DISABLED EXPANDE 0.00 0.00 0.00 0.00 369.61 0.00 0.00 0.00 0.00 0.00 0.00 0.00 369.61
2610 SSI DISABLED EXPANDE 1,696.40 1,696.40 2,120.50 3,392.80 2,641.76 2,217.66 0.00 0.00 0.00 0.00 0.00 0.00 13,765.52
2620 SSI DISABLED EXPANDE 452.37 -1,272.30 0.00 0.00 0.00 369.61 0.00 0.00 0.00 0.00 0.00 0.00 -450.32
SUBTOTAL: 94,846.79 91,222.54 94,998.40 71,588.08 111,674.04 80,530.91 0.00 0.00 0.00 0.00 0.00 0.00 544,860.76
3314 AHC CARE MALE 14-20 17,642.10 15,267.60 15,253.92 14,475.95 16,220.17 14,858.32 0.00 0.00 0.00 0.00 0.00 0.00 93,718.06
37
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS
3315 AHC CARE FEMALE 14-2 14,391.13 16,115.80 14,966.63 11,450.70 15,791.96 12,566.74 0.00 0.00 0.00 0.00 0.00 0.00 85,282.96
32,033.23 31,383.40 SUBTOTAL: 30,220.55 25,926.65 32,012.13 27,425.06 0.00 0.00 0.00 0.00 0.00 0.00 179,001.02
3614 AHC CARE/MI MALE 14- 89,131.69 85,935.89 86,393.27 68,789.01 93,543.81 70,600.80 0.00 0.00 0.00 0.00 0.00 0.00 494,394.47
3615 AHC CARE/MI FEMALE 1 85,555.10 80,620.04 80,291.70 57,423.12 84,009.15 63,168.25 0.00 0.00 0.00 0.00 0.00 0.00 451,067.36
SUBTOTAL: 174,686.79 166,555.93 166,684.97 126,212.13 177,552.96 133,769.05 0.00 0.00 0.00 0.00 0.00 0.00 945,461.83
TOTAL: 10,317,771.97 10,302,391.28 10,317,720.11 7,246,178.97 11,991,321.07 8,973,783.57 0.00 0.00 0.00 0.00 0.00 0.00 59,149,166.97
38
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
1000 TANF WITH MEDICARE 0.10 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.10
1005 TANF 14-20 FEMALE WI 0.00 2.00 2.00 2.00 2.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 9.00
1010 TANF NON-MEDICARE 250.93 246.02 240.15 186.26 282.39 238.40 0.00 0.00 0.00 0.00 0.00 0.00 1,444.15
1011 TANF <1 M & F NON-ME 239.96 251.41 246.48 0.00 506.14 237.52 0.00 0.00 0.00 0.00 0.00 0.00 1,481.51
1012 TANF 01-05 M & F NON 2,085.12 2,073.10 2,116.56 1,072.59 3,006.86 2,016.27 0.00 0.00 0.00 0.00 0.00 0.00 12,370.50
1013 TANF 06-13 M & F NON 2,617.07 2,642.24 2,642.50 2,025.06 3,367.33 2,720.19 0.00 0.00 0.00 0.00 0.00 0.00 16,014.39
1014 TANF 14-20 MALE NON- 550.79 544.34 545.49 374.13 718.74 549.31 0.00 0.00 0.00 0.00 0.00 0.00 3,282.80
1015 TANF 14-20 FEMALE NO 678.94 656.29 677.71 480.27 889.38 711.47 0.00 0.00 0.00 0.00 0.00 0.00 4,094.06
1017 TANF 21-44 FEMALE NO 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4.00
2200 SSI DISABLED WITH ME 16.00 27.12 16.00 6.00 12.00 9.00 0.00 0.00 0.00 0.00 0.00 0.00 86.12
2210 SSI DISABLED NON-MED 10,170.55 10,161.42 10,133.48 8,080.85 12,262.72 10,143.08 0.00 0.00 0.00 0.00 0.00 0.00 60,952.10
2220 SSI DISABLED WITH QM 31.56 31.06 43.54 43.93 55.41 45.60 0.00 0.00 0.00 0.00 0.00 0.00 251.10
2300 SSI BLIND WITH MEDIC 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2.00
2310 SSI BLIND NON-MEDICA 94.00 87.00 88.00 68.00 112.46 94.36 0.00 0.00 0.00 0.00 0.00 0.00 543.82
2320 SSI BLIND WITH QMB 0.00 0.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 4.00
4303 SOBRA CHILD 06-13 M 1.00 1.00 1.00 0.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4.00
4304 SOBRA CHILD 14-20 MA 1.00 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 6.00
4305 SOBRA CHILD 14-20 FE 0.00 0.00 0.00 0.00 1.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 3.00
4311 SOBRA CHILD <1 M & F 526.18 505.45 522.65 0.00 1,033.08 520.79 0.00 0.00 0.00 0.00 0.00 0.00 3,108.15
4312 SOBRA CHILD 01-05 M 2,340.24 2,319.15 2,278.21 1,212.66 3,183.71 2,222.19 0.00 0.00 0.00 0.00 0.00 0.00 13,556.16
4313 SOBRA CHILD 06-13 M 2,644.57 2,664.87 2,668.19 2,056.73 3,223.66 2,653.70 0.00 0.00 0.00 0.00 0.00 0.00 15,911.72
4314 SOBRA CHILD 14-20 MA 611.80 630.07 640.13 451.86 785.64 636.41 0.00 0.00 0.00 0.00 0.00 0.00 3,755.91
4315 SOBRA CHILD 14-20 FE 716.26 724.40 740.05 470.20 1,008.48 765.12 0.00 0.00 0.00 0.00 0.00 0.00 4,424.51
5015 SOBRA PREG 14-20 FEM 39.00 39.93 34.25 24.86 44.11 37.03 0.00 0.00 0.00 0.00 0.00 0.00 219.18
23,617.07 23,609.87 SUBTOTAL: 23,639.39 16,558.40 30,498.11 23,605.44 0.00 0.00 0.00 0.00 0.00 0.00 141,528.28
1111 TANF EXPANDED <1 M&F 2.00 2.00 1.00 0.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 7.00
1112 TANF EXPANDED 01-05 23.28 22.00 26.00 9.00 38.64 19.00 0.00 0.00 0.00 0.00 0.00 0.00 137.92
1113 TANF EXPANDED 06-13 97.69 96.00 93.06 79.00 121.60 101.00 0.00 0.00 0.00 0.00 0.00 0.00 588.35
1114 TANF EXPANDED 14-20 36.00 42.09 39.00 26.00 45.00 32.00 0.00 0.00 0.00 0.00 0.00 0.00 220.09
1115 TANF EXPANDED 14-20 58.60 50.00 57.93 46.80 74.04 56.73 0.00 0.00 0.00 0.00 0.00 0.00 344.10
2410 SSI AGED EXPANDED NO 1.00 0.00 0.00 0.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 3.00
2420 SSI AGED EXPANDED WI 0.00 2.00 2.00 0.00 2.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 7.00
2600 SSI DISABLED EXPANDE 0.00 0.00 0.00 0.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1.00
2610 SSI DISABLED EXPANDE 4.00 4.00 5.00 8.00 7.00 6.00 0.00 0.00 0.00 0.00 0.00 0.00 34.00
2620 SSI DISABLED EXPANDE 1.06 -3.00 0.00 0.00 0.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 -0.94
SUBTOTAL: 223.63 215.09 223.99 168.80 292.28 217.73 0.00 0.00 0.00 0.00 0.00 0.00 1,341.52
3314 AHC CARE MALE 14-20 41.59 36.00 35.97 34.13 43.00 40.20 0.00 0.00 0.00 0.00 0.00 0.00 230.89
39
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS
3315 AHC CARE FEMALE 14-2 33.93 38.00 35.29 27.00 41.73 34.00 0.00 0.00 0.00 0.00 0.00 0.00 209.95
SUBTOTAL: 75.52 74.00 71.26 61.13 84.73 74.20 0.00 0.00 0.00 0.00 0.00 0.00 440.84
3614 AHC CARE/MI MALE 14- 210.16 202.63 203.70 162.20 247.28 191.17 0.00 0.00 0.00 0.00 0.00 0.00 1,217.14
3615 AHC CARE/MI FEMALE 1 201.73 190.09 189.32 135.40 220.63 171.20 0.00 0.00 0.00 0.00 0.00 0.00 1,108.37
SUBTOTAL: 411.89 392.72 393.02 297.60 467.91 362.37 0.00 0.00 0.00 0.00 0.00 0.00 2,325.51
TOTAL: 24,328.11 24,291.68 24,327.66 17,085.93 31,343.03 24,259.74 0.00 0.00 0.00 0.00 0.00 0.00 145,636.15
40
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
1005 TANF 14-20 FEMALE WI 0.00 0.00 0.00 0.00 0.00 1,120.68 0.00 0.00 0.00 0.00 0.00 0.00 1,120.68
1006 TANF 21-44 MALE WITH -4,207.25 4,179.38 7,189.35 4,227.72 2,464.30 1,808.75 0.00 0.00 0.00 0.00 0.00 0.00 15,662.25
1007 TANF 21-44 FEMALE WI 12,547.23 11,552.94 6,002.57 10,716.53 6,921.52 8,479.37 0.00 0.00 0.00 0.00 0.00 0.00 56,220.16
1008 TANF 45-64 M & F WIT 5,677.06 7,273.96 10,256.01 14,306.58 6,704.65 15,789.52 0.00 0.00 0.00 0.00 0.00 0.00 60,007.78
1009 TANF 65+ M & F WITH 1,630.29 4,749.43 4,131.28 1,490.21 1,910.36 693.34 0.00 0.00 0.00 0.00 0.00 0.00 14,604.91
1011 TANF <1 M & F NON-ME 1,511,673.58 1,815,945.64 1,799,110.97 2,177,763.79 1,419,841.07 1,684,858.47 0.00 0.00 0.00 0.00 0.00 0.00 10,409,193.52
1012 TANF 01-05 M & F NON 2,395,775.38 2,397,801.31 2,616,070.44 3,418,268.74 2,217,349.26 2,555,667.27 0.00 0.00 0.00 0.00 0.00 0.00 15,600,932.40
1013 TANF 06-13 M & F NON 2,078,466.74 2,962,285.56 3,049,564.01 3,704,719.31 2,819,934.48 2,711,129.71 0.00 0.00 0.00 0.00 0.00 0.00 17,326,099.81
1014 TANF 14-20 MALE NON- 459,325.48 903,608.29 797,505.82 666,405.34 679,735.88 594,337.69 0.00 0.00 0.00 0.00 0.00 0.00 4,100,918.50
1015 TANF 14-20 FEMALE NO 1,177,278.44 1,189,532.68 1,591,102.10 1,276,585.82 1,066,945.74 1,318,828.91 0.00 0.00 0.00 0.00 0.00 0.00 7,620,273.69
1016 TANF 21-44 MALE NON- 1,250,233.95 1,283,736.82 1,501,582.28 1,478,813.21 1,224,942.16 1,158,220.62 0.00 0.00 0.00 0.00 0.00 0.00 7,897,529.04
1017 TANF 21-44 FEMALE NO 5,880,267.45 5,656,821.00 7,012,566.00 6,642,663.68 5,586,919.19 5,814,677.48 0.00 0.00 0.00 0.00 0.00 0.00 36,593,914.80
1018 TANF 45-64 M & F NON 1,442,653.11 1,518,234.97 1,797,381.18 1,626,834.67 1,434,672.10 1,412,659.31 0.00 0.00 0.00 0.00 0.00 0.00 9,232,435.34
1019 TANF 65+ M & F NON-M 294.00 588.00 -1,610.00 -1,992.00 996.11 0.00 0.00 0.00 0.00 0.00 0.00 0.00 -1,723.89
1027 TANF 21-44 FEMALE WI 294.00 294.00 -272.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 316.00
1028 TANF 45-64 M & F WIT 914.88 3,847.89 1,977.99 3,328.41 980.30 112.10 0.00 0.00 0.00 0.00 0.00 0.00 11,161.57
1029 TANF 65+ M & F WITH 316.00 54.14 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 370.14
2100 SSI AGED WITH MEDICA 74,750.86 107,261.48 77,448.14 106,581.27 62,418.82 55,621.84 0.00 0.00 0.00 0.00 0.00 0.00 484,082.41
2110 SSI AGED NON-MEDICAR 123,023.03 125,859.45 90,224.52 132,948.17 85,250.49 127,896.96 0.00 0.00 0.00 0.00 0.00 0.00 685,202.62
2120 SSI AGED WITH QMB 214,588.27 512,794.72 365,390.77 452,373.19 345,095.10 358,503.89 0.00 0.00 0.00 0.00 0.00 0.00 2,248,745.94
2200 SSI DISABLED WITH ME 215,389.47 383,865.57 369,513.01 406,941.25 239,198.84 268,889.20 0.00 0.00 0.00 0.00 0.00 0.00 1,883,797.34
2210 SSI DISABLED NON-MED 6,882,846.45 7,698,547.84 8,872,083.71 8,481,669.93 7,434,099.69 7,306,455.19 0.00 0.00 0.00 0.00 0.00 0.00 46,675,702.81
2220 SSI DISABLED WITH QM 777,192.65 1,287,754.52 932,206.66 1,311,634.51 938,473.11 955,603.05 0.00 0.00 0.00 0.00 0.00 0.00 6,202,864.50
2300 SSI BLIND WITH MEDIC 1,139.42 9,268.46 1,916.85 2,716.91 3,100.17 2,837.24 0.00 0.00 0.00 0.00 0.00 0.00 20,979.05
2310 SSI BLIND NON-MEDICA 48,283.89 40,770.54 105,133.46 73,789.39 37,129.50 50,424.40 0.00 0.00 0.00 0.00 0.00 0.00 355,531.18
2320 SSI BLIND WITH QMB 8,146.40 14,170.25 7,230.91 10,132.37 11,095.60 5,757.33 0.00 0.00 0.00 0.00 0.00 0.00 56,532.86
4311 SOBRA CHILD <1 M & F 1,674,900.63 2,272,024.73 1,790,833.46 2,333,622.24 1,554,599.34 1,650,737.57 0.00 0.00 0.00 0.00 0.00 0.00 11,276,717.97
4312 SOBRA CHILD 01-05 M 1,230,627.20 1,221,403.35 1,230,264.32 1,668,118.89 1,124,886.56 1,272,561.40 0.00 0.00 0.00 0.00 0.00 0.00 7,747,861.72
4313 SOBRA CHILD 06-13 M 1,311,261.18 1,472,310.29 1,647,739.86 1,820,656.84 1,402,920.76 1,410,489.16 0.00 0.00 0.00 0.00 0.00 0.00 9,065,378.09
4314 SOBRA CHILD 14-20 MA 483,103.43 761,220.78 749,552.88 679,441.13 595,743.94 580,618.10 0.00 0.00 0.00 0.00 0.00 0.00 3,849,680.26
4315 SOBRA CHILD 14-20 FE 810,959.10 1,029,558.46 981,377.67 772,721.22 1,040,797.80 778,051.57 0.00 0.00 0.00 0.00 0.00 0.00 5,413,465.82
5007 SOBRA PREG 21-44 FEM 51.20 1,293.67 39.24 0.00 433.50 28.45 0.00 0.00 0.00 0.00 0.00 0.00 1,846.06
5015 SOBRA PREG 14-20 FEM 591,569.93 576,664.08 778,735.36 526,742.07 470,643.06 515,109.94 0.00 0.00 0.00 0.00 0.00 0.00 3,459,464.44
5017 SOBRA PREG 21-44 FEM 1,299,563.20 1,426,317.04 1,622,849.27 1,613,187.48 1,380,157.64 1,356,220.52 0.00 0.00 0.00 0.00 0.00 0.00 8,698,295.15
5018 SOBRA PREG 45-64 FEM 1,396.35 3,399.53 9,957.18 11,890.62 9,433.93 4,778.30 0.00 0.00 0.00 0.00 0.00 0.00 40,855.91
5510 SOBRA FPS FEMALE WIT 19,348.00 13,684.00 13,646.00 19,498.00 23,263.95 25,143.80 0.00 0.00 0.00 0.00 0.00 0.00 114,583.75
31,981,281.00 36,718,674.77 39,838,701.27 41,448,797.49 SUBTOTAL: 33,229,058.92 34,004,111.13 0.00 0.00 0.00 0.00 0.00 0.00 217,220,624.58
3100 TRANSPLANT OPTION 1 51.73 1.35 5,511.43 324.91 17.31 0.00 0.00 0.00 0.00 0.00 0.00 0.00 5,906.73
41
RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL
For the Period Ending December 31, 2012
ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES
SUBTOTAL: 51.73 1.35 5,511.43 324.91 17.31 0.00 0.00 0.00 0.00 0.00 0.00 0.00 5,906.73
1106 TANF EXPANDED 21-44 8,168.09 13,919.24 12,397.68 24,703.27 13,404.01 13,401.69 0.00 0.00 0.00 0.00 0.00 0.00 85,993.98
1107 TANF EXPANDED 21-44 12,944.26 29,142.92 22,874.19 51,393.86 28,864.23 26,626.99 0.00 0.00 0.00 0.00 0.00 0.00 171,846.45
1108 TANF EXPANDED 45-64 79,430.84 112,508.02 67,155.39 97,284.87 84,695.33 61,994.01 0.00 0.00 0.00 0.00 0.00 0.00 503,068.46
1109 TANF EXPANDED 65+ M& 9,337.40 15,637.28 11,969.29 15,452.22 7,354.10 8,582.63 0.00 0.00 0.00 0.00 0.00 0.00 68,332.92
1111 TANF EXPANDED <1 M&F 1,371.30 306.43 982.47 837.71 1,596.44 2,244.55 0.00 0.00 0.00 0.00 0.00 0.00 7,338.90
1112 TANF EXPANDED 01-05 18,067.16 11,475.47 15,676.69 20,458.18 16,692.66 11,824.33 0.00 0.00 0.00 0.00 0.00 0.00 94,194.49
1113 TANF EXPANDED 06-13 31,399.41 43,055.73 45,723.40 64,433.49 42,918.00 51,317.91 0.00 0.00 0.00 0.00 0.00 0.00 278,847.94
1114 TANF EXPANDED 14-20 14,812.09 23,863.24 32,266.34 26,283.42 54,733.28 28,949.45 0.00 0.00 0.00 0.00 0.00 0.00 180,907.82
1115 TANF EXPANDED 14-20 71,061.54 66,999.22 75,376.95 50,006.19 47,803.92 64,390.81 0.00 0.00 0.00 0.00 0.00 0.00 375,638.63
1116 TANF EXPANDED 21-44 586,805.37 678,241.40 624,339.62 735,783.15 583,084.59 612,135.01 0.00 0.00 0.00 0.00 0.00 0.00 3,820,389.14
1117 TANF EXPANDED 21-44 1,573,375.76 1,545,793.44 1,775,465.91 1,620,664.05 1,332,327.49 1,446,518.79 0.00 0.00 0.00 0.00 0.00 0.00 9,294,145.44
1118 TANF EXPANDED 45-64 935,675.86 1,033,489.60 979,453.39 936,784.92 779,388.93 814,432.99 0.00 0.00 0.00 0.00 0.00 0.00 5,479,225.69
1119 TANF EXPANDED 65+ M& 0.00 1,264.00 346.41 -1,168.12 632.00 810.40 0.00 0.00 0.00 0.00 0.00 0.00 1,884.69
1126 TANF EXPANDED 21-44 1,593.52 1,878.53 865.53 814.08 0.00 1,786.49 0.00 0.00 0.00 0.00 0.00 0.00 6,938.15
1127 TANF EXPANDED 21-44 72.39 0.00 0.00 37.79 0.00 4.26 0.00 0.00 0.00 0.00 0.00 0.00 114.44
1128 TANF EXPANDED 45-64 1,369.17 4,483.75 3,031.91 6,987.95 5,506.33 3,907.72 0.00 0.00 0.00 0.00 0.00 0.00 25,286.83
1129 TANF EXPANDED 65+ M& 376.93 544.65 1,613.11 800.52 195.55 441.93 0.00 0.00 0.00 0.00 0.00 0.00 3,972.69
2400 SSI AGED EXPANDED WI 14,173.56 8,537.52 20,900.81 19,515.60 14,482.33 11,823.45 0.00 0.00 0.00 0.00 0.00 0.00 89,433.27
2410 SSI AGED EXPANDED NO 59,018.16 94,645.31 93,985.33 76,934.47 74,296.89 107,747.04 0.00 0.00 0.00 0.00 0.00 0.00 506,627.20
2420 SSI AGED EXPANDED WI 219,999.03 383,968.92 264,707.18 350,613.81 280,610.70 312

Object Description

Rating
TITLE	Appropriation status report (ASR) : fiscal year... through...
CREATOR	Arizona Health Care Cost Containment System. Division of Business and Finance.
SUBJECT	Arizona Health Care Cost Containment System--Finance; Arizona Health Care Cost Containment System--Appropriations and expenditures
Browse Topic	Science and technology
DESCRIPTION	This title contains one or more publications.
Language	English
Publisher	Arizona Health Care Cost Containment System
Material Collection	State Documents
Source Identifier	HCC 6.3:A 66
Location	60747089
REPOSITORY	Arizona State Library, Archives and Public Records--Law and Research Library.

Description

TITLE	Arizona Health Care Cost Containment System Appropriation Status Report Fiscal Year 2013 through December 31, 2012
DESCRIPTION	97 pages (PDF version). File size: 915 KB
TYPE	Text
RIGHTS MANAGEMENT	Copyright to this resource is held by the creating agency and is provided here for educational purposes only. It may not be downloaded, reproduced or distributed in any format without written permission of the creating agency. Any attempt to circumvent the access controls placed on this file is a violation of United States and international copyright laws, and is subject to criminal prosecution.
DATE ORIGINAL	2012-01-25
Time Period	2010s (2010-2019)
ORIGINAL FORMAT	Born Digital
Source Identifier	HCC 6.3:A 66
Location	o60747089
DIGITAL IDENTIFIER	ASR201212.pdf
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REPOSITORY	Arizona State Library, Archives and Public Records--State Library of Arizona.
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Full Text	Janice K. Brewer, Governor Thomas J. Betlach, Director 801 East Jefferson, Phoenix, AZ 85034 PO Box 25520, Phoenix, AZ 85002 Phone: 602-417-4000 www.azahcccs.gov Our first care is your health care ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM January 25, 2013 The Honorable Andy Biggs, President Arizona State Senate 1700 West Washington Phoenix, AZ 85007 The Honorable Andy Tobin, Speaker Arizona House of Representatives 1700 West Washington Phoenix, AZ 85007 SUBJECT: FY 2013 Appropriation Status Report for the Period Ended December 31, 2012 Dear President Biggs and Speaker Tobin: Pursuant to A.R.S. §’s 36-2920 and 36-2994, enclosed is the Arizona Health Care Cost Containment System’s (AHCCCS) Appropriation Status Report (ASR) for the period ended December 31, 2012. Status Summary - As part of the FY 2014 budget request submitted to the Governor’s Office of Strategic Planning and Budgeting, a FY 2013 rebase was prepared. This rebase indicates that the current appropriations are expected to be sufficient to cover projected agency expenditures with a small estimated surplus. For purposes of this report, projected annual expenditures remain equal to the appropriations. The projected annual expenditures are subject to several factors including: caseload trends, expenditure trends, potential Agency audit liabilities, information system issues, CMS decisions, and tobacco funding. AHCCCS will continue to monitor these factors and will provide a projected annual appropriation estimate when more data is available. Expenditure flows for the first six months of FY 2013 have been impacted by changes to the AHCCCS claims and encounter systems to become compliant with the HIPAA 5010 requirements (5010 refers to an electronic file format mandated by HIPAA for both claims and encounter submissions). These system conversions, and the corresponding changes made by AHCCCS health plans and program contractors, has resulted in abnormally low and erratic Fee-for- Service and Reinsurance expenditures and has also impacted Prescription Drug Rebate encounters and invoicing. AHCCCS expects the final expenditures/collections for the year to return to normalized levels. However, the year-to-date expenditure flows remain unstable and caution should be exercised when analyzing the year-to-date data. The Honorable Andy Biggs The Honorable Andy Tobin January 25, 2013 Page 2 Enrollment Update – December 2012 enrollment, excluding Healthcare Group and certain Medicare Cost Sharing members, is 1,266,727 members, a 4,088 member decrease over the prior month. Enrollment for January 2013 increased to 1,268,918 members, a 2,191 member increase. Childless Adult Enrollment Freeze Impacts The Phase-Out Plan for Childless Adults was approved by CMS on July 1, 2011 with an effective date of July 8, 2011. The January 1, 2013 Childless Adults enrollment is 86,719, which represents a decline of 137,773 members from the 224,492 members enrolled as of June 1, 2011. This overall decrease includes a transfer of 13,289 childless adults who were seriously mentally ill, or age 65 and over, or had Medicare or HIV/AIDS to the Supplemental Security Income Medical Assistance Only program as required by the Phase-Out Plan. Additional information reported to CMS regarding the impact of the above changes is located on the AHCCCS website at: http://www.azahcccs.gov/reporting/Downloads/1115waiver/CMS_PhaseOutActivityMonthlyRep ort.pdf KidsCare Enrollment Freeze and KidsCare II Impacts KidsCare and KidsCare II enrollment – The January 1, 2013 KidsCare enrollment is 34,125, which is comprised of 8,281 members in the state plan program and 25,844 members in the KidsCare II waiver program. Enrollment for the KidsCare state plan program, which has been frozen since January 1, 2010 due to budget deficits, declined by 98 members from the prior month and 37,539 members from the 45,820 members enrolled as of January 1, 2010. Tobacco Funds Revenue Update – Tobacco tax collections through December 2012 are $2.0 million less than the AHCCCS monthly projected flows. AHCCCS will continue to monitor the tobacco funds revenue collections to determine any impact on the FY 2013 appropriations. If you have any questions about this report, please do not hesitate to call me at (602) 417-4111 or Jim Cockerham at (602) 417-4059. Sincerely, Thomas J. Betlach Director The Honorable Andy Biggs The Honorable Andy Tobin January 25, 2013 Page 3 Enclosure cc: The Honorable Janice K. Brewer, Governor The Honorable Don Shooter, Chairman, Senate Appropriations Committee The Honorable John Kavanagh, Chairman, House Appropriations Committee The Honorable Nancy Barto, Chairman, Senate Health and Human Services Committee The Honorable Heather Carter, Chairman, House Health and Human Services Committee John Arnold, Director, Governor’s Office of Strategic Planning and Budgeting Richard Stavneak, Director, Joint Legislative Budget Committee Arizona Health Care Cost Containment System Appropriation Status Report (ASR) Fiscal Year 2013 Through December 31, 2012 Prepared by: Division of Business and Finance Arizona Health Care Cost Containment System Appropriation Status Report Table of Contents • APPROPRIATED SOURCES AND USES OF FUNDS Page Summary of Appropriated Expenditures for SFY 2013 2 Appropriated Expenditures by Funding Source 3 Appropriated Revenue Received Detail Schedule 4 • FOOTNOTES 6 • CASELOAD AND EXPENDITURES BY RATE CODE 9 ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM APPROPRIATION STATUS REPORT APPROPRIATED SOURCES AND USES OF FUNDS (A) (B) (A) - (B) EXPENDITURE PROJECTED ANNUAL PLAN EXPENDITURES VARIANCE ANNUAL ANNUALIZED APPROPRIATION YTD YTD YTD EXPENDITURES VARIANCE APPROPRIATIONS: ADMINISTRATION AHCCCS Operating Lump Sum $ 77,682,100 $ 38,689,900 $ 34,368,387 $ 4,321,513 $ 77,682,100 $ - AHCCCS Prop 204 Administration 8,934,500 3,906,600 3,926,166 (19,566) 8,934,500 - DES Eligibility 54,247,600 26,960,400 24,134,779 2,825,621 54,247,600 - DES Prop 204 Eligibility 37,945,700 18,917,200 4,830,045 14,087,155 37,945,700 - TOTAL ADMINISTRATION 178,809,900 88,474,100 67,259,376 21,214,724 178,809,900 - Traditional Medicaid Services 3,420,887,100 1,622,435,000 1,592,239,910 30,195,090 3,420,887,100 - Proposition 204 Services 1,166,614,700 584,215,800 571,917,340 12,298,460 1,166,614,700 - Children's Rehabilitative Services 127,941,500 65,217,800 59,903,975 5,313,825 127,941,500 - KidsCare Services 21,622,300 12,248,100 10,126,940 2,121,160 21,622,300 - ALTCS Services 1,177,910,000 548,936,600 548,522,259 414,341 1,177,910,000 - Disproportionate Share Payments 13,487,100 - - - 13,487,100 - DSH Voluntary 77,248,900 44,086,900 44,086,780 120 77,248,900 - Rural Hospitals 13,858,100 - - - 13,858,100 - Graduate Medical Education 169,735,300 164,853,700 164,853,796 (96) 169,735,300 - TOTAL PROGRAMMATIC 6,189,305,000 3,041,993,900 2,991,651,001 50,342,899 6,189,305,000 - TOTAL EXPENDITURES $ 6,368,114,900 $ 3,130,468,000 $ 3,058,910,377 $ 71,557,623 $ 6,368,114,900 $ - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM FY 2013 APPROPRIATION STATUS REPORT For the Period Ending December 31, 2012 SUMMARY OF APPROPRIATED EXPENDITURES 2 (A) (B) (A) - (B) EXPENDITURE PROJECTED ANNUAL PLAN EXPENDITURES VARIANCE ANNUAL ANNUALIZED APPROPRIATION YTD YTD YTD EXPENDITURES VARIANCE STATE - GENERAL FUND Administrative Expenditures $ 52,247,100 $ 26,210,700 $ 24,923,662 1 ,287,038 $ 52,247,100 $ - Proposition 204 - Administrative Expenditures 21,081,800 10,149,700 3,609,157 6,540,543 21,081,800 - Programmatic Expenditures Traditional Medicaid Services 914,805,100 424,468,500 411,471,906 1 2,996,594 914,805,100 - Proposition 204 Services 191,023,200 145,647,700 136,111,314 9 ,536,386 191,023,200 - Children's Rehabilitative Services 43,285,600 21,791,100 20,035,631 1,755,469 43,285,600 - KidsCare Services 5,132,600 2,875,400 2,223,217 652,183 5,132,600 - ALTCS Services 162,594,300 77,207,900 77,346,707 ( 138,807) 162,594,300 - DSH and Rural Hospitals 7,942,600 - - - 7,942,600 - TOTAL GF EXPENDITURES 1,398,112,300 708,351,000 675,721,595 32,629,405 1,398,112,300 - FEDERAL Administrative Expenditures 77,259,800 38,238,000 32,974,224 5 ,263,777 77,259,800 - Proposition 204 - Administrative Expenditures 22,577,300 11,063,700 4,341,778 6,721,922 22,577,300 - Programmatic Expenditures Traditional Medicaid Services 2,201,471,200 1,034,496,000 1,028,003,320 6 ,492,680 2,201,471,200 - Proposition 204 Services 816,000,700 408,022,800 406,010,626 2 ,012,174 816,000,700 - Children's Rehabilitative Services 84,655,900 43,426,700 39,868,344 3,558,356 84,655,900 - KidsCare Services 14,531,200 8,255,900 7,180,476 1,075,424 14,531,200 - ALTCS Services 752,042,100 346,723,300 343,087,813 3 ,635,487 752,042,100 - DSH and Rural Hospitals 19,402,600 - - - 19,402,600 - DSH Voluntary 51,214,600 29,259,400 2 9,259,363 37 51,214,600 - Graduate Medical Education 114,942,700 112,559,100 112,768,902 (209,802) 114,942,700 - TOTAL FEDERAL EXPENDITURES 4,154,098,100 2,032,044,900 2,003,494,845 2 8,550,055 4,154,098,100 - COUNTY Administrative Expenditures Proposition 204 - BNCF 3,221,100 1,610,400 805,275 805,125 3,221,100 - Programmatic Expenditures Traditional Medicaid Services Acute Care 50,901,700 25,450,800 25,450,800 - 50,901,700 - ALTCS Services 243,220,500 115,493,200 117,444,111 ( 1,950,911) 243,220,500 - TOTAL COUNTY EXPENDITURES 297,343,300 142,554,400 143,700,186 (1,145,786) 297,343,300 - TOBACCO FUNDS Programmatic Expenditures Traditional Medicaid Services Acute Care - Medically Needy 38,295,800 19,594,400 19,147,900 4 46,500 38,295,800 - Proposition 204 Services - Emergency Health Services 19,222,900 9,890,400 9,611,450 2 78,950 19,222,900 - Proposition 204 Services - Proposition 204 Protection 40,367,900 20,654,900 20,183,950 4 70,950 40,367,900 - Proposition 204 Services - ATLSF 100,000,000 - - - 100,000,000 - TOTAL TOBACCO EXPENDITURES 197,886,600 50,139,700 48,943,300 1,196,400 197,886,600 - OTHER Administrative Expenditures HCG 2,307,000 1,144,200 550,431 593,769 2,307,000 - Prescription Drug Rebate Program 115,800 57,400 54,849 2,551 115,800 - Programmatic Expenditures Acute Care - Prescription Drug Rebate Program State Match 63,741,300 31,870,500 31,870,650 ( 150) 63,741,300 - Acute Care - Prescription Drug Rebate Program Federal Authority 151,433,100 86,533,200 75,716,550 10,816,650 151,433,100 - Long Term Care - Prescription Drug Rebate Program State Match 6,093,900 2,890,700 3,046,950 ( 156,250) 6,093,900 - Long Term Care - Prescription Drug Rebate Program Federal Authority 13,959,200 6,621,500 6,979,600 ( 358,100) 13,959,200 - Traditional Medicaid Services - TPL 194,700 - 558,429 ( 558,429) 194,700 - ALTCS Services - TPL - - 617,078 (617,078) - - KidsCare Services Premiums 1,958,500 1,116,800 723,247 393,553 1,958,500 - Freedom to Work Premiums 44,200 21,600 20,355 1,245 44,200 - DSH Voluntary - Local Government Match 26,034,300 14,827,500 14,827,418 8 2 26,034,300 - GME Voluntary - Local Government Match 54,792,600 52,294,600 52,084,894 2 09,706 54,792,600 - TOTAL OTHER EXPENDITURES 320,674,600 197,378,000 187,050,451 1 0,327,549 320,674,600 - TOTAL Administrative Expenditures 178,809,900 88,474,100 67,259,376 21,214,724 178,809,900 - Acute Care 5,011,395,000 2,493,057,300 2,443,128,742 49,928,558 5,011,395,000 - Long Term Care 1,177,910,000 548,936,600 548,522,259 414,341 1,177,910,000 - TOTAL EXPENDITURES $ 6,368,114,900 $ 3,130,468,000 $ 3,058,910,377 $ 71,557,623 $ 6,368,114,900 $ - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM FY 2013 APPROPRIATION STATUS REPORT For the Period Ending December 31, 2012 APPROPRIATED EXPENDITURES BY FUNDING SOURCE 3 BUDGET BUDGET YTD GENERAL FUND: Traditional Medicaid Services & Administrative $ 1,018,280,400 $ 472,470,300 $ 456,431,199 Proposition 204 Services & Administrative 212,105,000 155,797,400 139,163,205 KidsCare Services 5,132,600 2,875,400 2,223,217 ALTCS Services 162,594,300 77,207,900 77,346,707 TOTAL 1,398,112,300 708,351,000 675,164,328 FEDERAL: Acute & Administrative 3,387,524,800 1,677,065,700 1,710,977,961 KidsCare Services 14,531,200 8,255,900 20,168,962 ALTCS Services 752,042,100 346,723,300 343,087,813 TOTAL 4,154,098,100 2,032,044,900 2,074,234,736 COUNTY: Acute & Administrative 54,122,800 27,061,200 26,870,698 ALTCS Services 243,220,500 115,493,200 121,610,262 TOTAL 297,343,300 142,554,400 148,480,960 TOBACCO FUNDS: Traditional Medicaid Services 38,295,800 19,594,400 19,147,900 Proposition 204 Services 159,590,800 30,545,300 29,795,400 TOTAL 197,886,600 50,139,700 48,943,300 OTHER: Administrative 2,422,800 1,201,600 605,280 Acute Care - Prescription Drug Rebate Program 215,174,400 118,403,700 107,587,200 Long Term Care - Prescription Drug Rebate Program 20,053,100 9,512,200 10,026,550 Acute TPL - Note 1 194,700 - 558,429 LTC TPL - Note 1 - - 617,078 KidsCare TPL - Note 1 - - 4,650 Member Premiums - CHIP 1,958,500 1,116,800 686,565 Member Premiums - Freedom to Work 44,200 21,600 20,355 DSH and GME Voluntary - Local Government Match 80,826,900 67,122,100 - TOTAL 320,674,600 197,378,000 120,106,106 TOTAL REVENUE $ 6,368,114,900 $ 3,130,468,000 $ 3,066,929,430 RECEIPTS YTD ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM FY 2013 APPROPRIATION STATUS REPORT APPROPRIATED REVENUE AND OTHER COLLECTIONS RECEIVED DETAIL SCHEDULE For the Period Ending December 31, 2012 4 ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM APPROPRIATION STATUS REPORT FOOTNOTES Note 1: Third Party Liability Collections: December 2012 December 2011 July 1, 2012 July 1, 2011 Gross Collections: December 31, 2012 December 31, 2011 Acute $ 326,641 $ 276,969 $ 3,403,019 $ 2,849,269 LTC 491,400 131,931 2,663,940 2,208,491 KidsCare 225 648 27,461 7,141 Total TPL Collections $ 818,266 $ 409,548 $ 6,094,420 $ 5,064,901 AHCCCS Net Collections (Net of Federal Share): Expenditure Offsets: Acute $ 40,497 $ - $ 558,429 $ - LTC 118,825 29,713 617,078 449,181 KidsCare - 34 4,650 104 Total Expenditure Offsets 159,322 29,747 1,180,157 449,285 Acute - 46,105 - 415,853 KidsCare - 99 - 1,196 Total General Fund Transfers - 46,204 - 417,049 Total Net State Match Collections $ 159,322 $ 75,951 $ 1,180,157 $ 866,334 FY 13 Total Note 2: Authorized Positions 1,370.1 Actual Positions as of December 31, 2012 952.6 ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM FY 2013 APPROPRIATION STATUS REPORT For the Period Ending December 31, 2012 State General Fund Transfers: 6 Note 3: Intergovernmental Service Agreement - State of Hawaii: Beginning Balance July 1, 2012 $ 1 ,108,157 Revenues 4,063,803 Transfers-In 73,640 Total Revenues 4,137,443 Expenditures 2,659,036 Transfers-out 247,500 Total Expenditures 2,906,536 Ending Balance December 31, 2012 $ 2,339,065 Note 4: Description Amount Medicare Part B Premiums $ 7,602,830 HHS-OIG & CMS Questioned Cost School Based Claiming Medicaid Administrative Costs 1 8,941,355 HHS-OIG & AHCCCS Self Reported School Based Claiming Direct Services Costs 2 1,209,756 HHS-OIG 47,753,941 ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM FY 2013 APPROPRIATION STATUS REPORT For the Period Ending December 31, 2012 Summary of HHS Office of Inspector General Questioned Costs and CMS Deferrals and Disallowances Liabilities. Schedule of Outstanding Liabilities As of December 31, 2012 Type Of the $2,339,065 ending balance, $1,574,891 represents restricted cash for prepaid expenses from the State of Hawaii for the projected expenditures through January 2013. 7 ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM APPROPRIATION STATUS REPORT CASELOAD AND EXPENDITURES BY RATE CODE JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM EXPENDITURE SUMMARY For the Period Ending December 31, 2012 TITLE XIX EXPANSION AND CONVERSION TITLE XIX BASE CAPITATION - ACUTE 190,359,793 194,206,483 190,830,304 198,584,854 196,020,918 196,190,915 0 0 0 0 0 0 1,166,193,267 CAPITATION - LTC 152,688,740 153,257,940 153,496,210 156,112,691 156,399,312 156,313,475 0 0 0 0 0 0 928,268,367 MENTAL HEALTH - CHILD 22,434,436 22,521,934 22,580,932 22,444,615 22,234,589 22,135,453 0 0 0 0 0 0 134,351,958 MENTAL HEALTH - ADULT 21,724,207 21,839,863 21,978,162 21,933,714 21,801,438 21,689,670 0 0 0 0 0 0 130,967,054 MENTAL HEALTH - CMDP 11,559,924 11,798,044 11,931,083 12,341,768 12,456,490 12,316,703 0 0 0 0 0 0 72,404,012 MENTAL HEALTH - GENERAL 12,335,269 12,400,940 12,479,468 12,454,230 12,379,122 12,315,659 0 0 0 0 0 0 74,364,688 CHILDREN'S REHAB SERVICES 10,016,205 10,013,229 10,025,816 7,022,452 11,670,082 8,732,059 0 0 0 0 0 0 57,479,843 FEE FOR SERVICE - ACUTE 31,985,996 36,726,635 39,850,816 41,464,151 33,232,797 34,022,034 0 0 0 0 0 0 217,282,429 EMERGENCY SERVICES - FEDERAL 5,740,726 7,478,425 7,226,613 8,968,936 6,221,186 6,491,211 0 0 0 0 0 0 42,127,097 FFS - FAMILY PLANNING 5,108 3,829 3,866 6,345 2,555 5,372 0 0 0 0 0 0 27,074 FFS MEDICAID IN PUBLIC SCHOOLS 327,337 279,377 148,968 759,960 409,788 461,077 0 0 0 0 0 0 2,386,507 QMB - FEE FOR SERVICE 88,441 285,525 245,884 138,387 304,350 183,419 0 0 0 0 0 0 1,246,006 INPATIENT INMATES FFS 2,520 4,074 1,238 1,342 420 0 0 0 0 0 0 0 9,594 COCONINO COUNTY INMATES FFS 0 363 756 8,381 3,593 137 0 0 0 0 0 0 13,230 PIMA COUNTY INMATES FFS 395 2,876 4,572 2,066 471 270 0 0 0 0 0 0 10,649 PINAL COUNTY INMATES FFS 820 32 862 8,502 6,901 17,792 0 0 0 0 0 0 34,910 COCHISE COUNTY INMATES FFS 0 0 6,092 0 0 0 0 0 0 0 0 0 6,092 FEE FOR SERVICE - LTC 7,219,483 10,048,283 8,979,744 10,991,559 9,106,862 9,293,480 0 0 0 0 0 0 55,639,411 LFFS MEDICAID IN PUBLIC SCHOOLS 297,597 507,272 318,151 893,223 708,268 776,933 0 0 0 0 0 0 3,501,443 REINSURANCE - ACUTE 9,148,489 3,357,764 -1,432,506 15,192,830 6,848,413 7,097,419 0 0 0 0 0 0 40,212,410 REINSURANCE - LTC 4,414,167 664,131 1,228,404 1,892,163 464,469 5,791,755 0 0 0 0 0 0 14,455,090 SMIB - ACUTE 8,614,585 8,676,358 8,769,427 9,207,290 8,996,036 9,016,093 0 0 0 0 0 0 53,279,789 HIB - ACUTE 251,103 241,244 253,068 255,162 256,786 250,000 0 0 0 0 0 0 1,507,362 Q1 1,383,004 1,420,452 1,490,863 1,684,071 1,562,811 1,549,010 0 0 0 0 0 0 9,090,211 SMIB - LTC 2,556,162 2,541,266 2,562,213 2,567,109 2,566,410 2,583,418 0 0 0 0 0 0 15,376,578 HIB - LTC 280,549 276,939 272,429 271,437 271,753 272,812 0 0 0 0 0 0 1,645,919 498,553,276 493,253,435 525,207,240 503,925,817 SUBTOTAL 493,435,056 507,506,166 0 0 0 0 0 0 3,021,880,990 CAPITATION - ACUTE 73,970,153 72,789,552 69,764,657 69,411,726 68,014,622 66,689,065 0 0 0 0 0 0 420,639,777 MENTAL HEALTH - CHILD 265,490 266,950 269,446 267,602 269,753 270,138 0 0 0 0 0 0 1,609,379 MENTAL HEALTH - ADULT 19,358,785 19,034,155 18,640,299 18,242,021 17,906,184 17,586,052 0 0 0 0 0 0 110,767,495 MENTAL HEALTH - CMDP 964 0 0 0 964 0 0 0 0 0 0 0 1,928 MENTAL HEALTH - GENERAL 10,992,154 10,807,825 10,584,189 10,358,042 10,167,349 9,985,574 0 0 0 0 0 0 62,895,132 CHILDREN'S REHAB SERVICES 301,567 289,162 291,904 223,727 321,239 241,725 0 0 0 0 0 0 1,669,324 FEE FOR SERVICE - ACUTE 12,131,280 13,463,248 12,772,478 13,061,045 11,018,885 10,573,554 0 0 0 0 0 0 73,020,490 EMERGENCY SERVICES - FEDERAL 767,033 1,331,856 1,134,174 1,241,696 926,906 995,780 0 0 0 0 0 0 6,397,446 FFS MEDICAID IN PUBLIC SCHOOLS 3,143 2,446 1,527 5,915 4,234 2,997 0 0 0 0 0 0 20,262 9 JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM EXPENDITURE SUMMARY For the Period Ending December 31, 2012 619,716,536 623,692,867 615,736,769 649,133,480 GRAND TOTAL 622,325,631 624,283,602 0 0 0 0 0 0 3,754,888,884 TITLE XXI - KidsCare TITLE XXI - HIFA PARENTS INPATIENT INMATES FFS 2,619 6,604 995 -14,234 36,816 2,624 0 0 0 0 0 0 35,424 COCONINO COUNTY INMATES FFS 403 130 0 0 0 0 0 0 0 0 0 0 533 MARICOPA CTY INMATES FFS 0 123 0 0 0 11,413 0 0 0 0 0 0 11,536 PIMA COUNTY INMATES FFS 11,916 4,882 0 6,479 6,176 19,900 0 0 0 0 0 0 49,353 PINAL COUNTY INMATES FFS 0 484 435 265 0 88 0 0 0 0 0 0 1,271 YUMA COUNTY INMATES FFS 0 0 0 0 0 -184 0 0 0 0 0 0 -184 COCHISE COUNTY INMATES FFS 0 0 2,597 0 0 177 0 0 0 0 0 0 2,773 REINSURANCE - ACUTE 2,154,316 48,314 873,670 2,581,905 1,592,527 1,588,170 0 0 0 0 0 0 8,838,903 SMIB - ACUTE 3,344,752 3,362,407 3,402,877 3,450,947 3,460,077 3,447,630 0 0 0 0 0 0 20,468,690 HIB - ACUTE 4,555 1,398 1,849 1,398 1,398 1,398 0 0 0 0 0 0 11,997 SUBTOTAL 123,309,129 121,409,534 117,741,096 118,838,535 113,727,132 111,416,101 0 0 0 0 0 0 706,441,527 TOTAL TITLE XIX 616,744,184 619,962,810 610,994,531 644,045,775 617,652,949 618,922,268 0 0 0 0 0 0 3,728,322,517 KidsCare - CAPITATION 1,890,882 2,664,196 3,409,987 3,575,194 3,238,745 3,793,541 0 0 0 0 0 0 18,572,546 KidsCare - FEE FOR SERVICE 76,314 54,880 41,405 77,893 94,508 64,369 0 0 0 0 0 0 409,370 KidsCare - MENTAL HEALTH 586,986 837,823 1,078,591 1,093,486 992,362 1,163,748 0 0 0 0 0 0 5,752,996 KidsCare - REINSURANCE 257,012 124 -83 163,858 61,330 118,459 0 0 0 0 0 0 600,699 KidsCare - CHILD REHAB SERVICES 161,158 173,033 212,337 177,274 285,737 221,218 0 0 0 0 0 0 1,230,756 SUBTOTAL 2,972,352 3,730,056 4,742,238 5,087,705 4,672,682 5,361,334 0 0 0 0 0 0 26,566,367 TOTAL TITLE XXI 2,972,352 3,730,056 4,742,238 5,087,705 4,672,682 5,361,334 0 0 0 0 0 0 26,566,367 10 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 ACUTE CAPITATION - AMOUNTS 1002 TANF 01-05 M & F WIT 0.00 104.41 104.41 109.10 109.10 109.10 0.00 0.00 0.00 0.00 0.00 0.00 536.12 1003 TANF 06-13 M & F WIT 111.86 111.86 111.86 120.39 230.59 120.39 0.00 0.00 0.00 0.00 0.00 0.00 806.95 1004 TANF 14-20 MALE WITH 0.00 163.60 163.60 161.14 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 488.34 1005 TANF 14-20 FEMALE WI 228.72 941.47 941.47 1,255.25 1,036.51 803.58 0.00 0.00 0.00 0.00 0.00 0.00 5,207.00 1006 TANF 21-44 MALE WITH 16,764.56 14,621.33 15,325.75 17,214.51 17,115.03 17,617.02 0.00 0.00 0.00 0.00 0.00 0.00 98,658.20 1007 TANF 21-44 FEMALE WI 73,648.98 70,089.48 69,937.70 69,101.98 64,585.40 63,810.76 0.00 0.00 0.00 0.00 0.00 0.00 411,174.30 1008 TANF 45-64 M & F WIT 64,823.98 60,166.65 62,119.72 64,164.10 62,600.12 65,264.28 0.00 0.00 0.00 0.00 0.00 0.00 379,138.85 1009 TANF 65+ M & F WITH 14,019.63 12,421.46 12,575.94 15,177.92 16,080.55 16,329.76 0.00 0.00 0.00 0.00 0.00 0.00 86,605.26 100C TANF 06-13 M & F WIT 0.00 0.00 0.00 0.00 53.80 0.00 0.00 0.00 0.00 0.00 0.00 0.00 53.80 100F TANF 21-44 MALE WITH 307.10 248.93 1,138.16 183.21 179.76 277.31 0.00 0.00 0.00 0.00 0.00 0.00 2,334.47 100G TANF 21-44 FEMALE WI 2,255.25 1,296.71 1,177.39 554.87 2,250.97 1,836.15 0.00 0.00 0.00 0.00 0.00 0.00 9,371.34 100H TANF 44-64 M & F WIT 1,949.33 1,935.66 177.60 553.65 939.47 374.42 0.00 0.00 0.00 0.00 0.00 0.00 5,930.13 100J TANF 65+ M & F WITH 658.86 43.80 115.44 568.08 1,049.59 43.89 0.00 0.00 0.00 0.00 0.00 0.00 2,479.66 1011 TANF <1 M & F NON-ME 6,855,702.89 6,936,653.52 6,879,519.69 7,187,048.69 7,093,597.08 7,121,067.37 0.00 0.00 0.00 0.00 0.00 0.00 42,073,589.24 1012 TANF 01-05 M & F NON 8,986,067.52 9,046,262.29 8,953,524.24 9,203,340.83 9,118,042.65 9,054,216.30 0.00 0.00 0.00 0.00 0.00 0.00 54,361,453.83 1013 TANF 06-13 M & F NON 12,176,083.88 12,337,815.29 12,329,525.00 12,747,656.27 12,713,234.03 12,721,427.83 0.00 0.00 0.00 0.00 0.00 0.00 75,025,742.30 1014 TANF 14-20 MALE NON- 3,314,054.87 3,358,445.46 3,363,411.20 3,444,069.65 3,450,636.12 3,475,437.33 0.00 0.00 0.00 0.00 0.00 0.00 20,406,054.63 1015 TANF 14-20 FEMALE NO 6,500,801.72 6,571,685.95 6,554,635.95 6,655,776.96 6,647,511.26 6,684,394.07 0.00 0.00 0.00 0.00 0.00 0.00 39,614,805.91 1016 TANF 21-44 MALE NON- 3,059,869.18 3,099,449.72 3,081,378.22 3,133,059.28 3,089,750.74 3,068,793.06 0.00 0.00 0.00 0.00 0.00 0.00 18,532,300.20 1017 TANF 21-44 FEMALE NO 19,136,282.09 19,435,857.63 19,376,953.48 19,555,787.62 19,449,261.50 19,369,270.96 0.00 0.00 0.00 0.00 0.00 0.00 116,323,413.28 1018 TANF 45-64 M & F NON 5,912,166.57 6,002,373.36 5,989,185.76 6,290,686.83 6,268,888.10 6,280,489.73 0.00 0.00 0.00 0.00 0.00 0.00 36,743,790.35 1019 TANF 65+ M & F NON-M 17,066.43 19,175.74 16,656.54 18,421.30 15,726.84 14,250.52 0.00 0.00 0.00 0.00 0.00 0.00 101,297.37 101A TANF < 1 M & F NON-M 351,640.07 426,760.88 332,188.99 361,174.93 342,019.95 390,618.00 0.00 0.00 0.00 0.00 0.00 0.00 2,204,402.82 101B TANF 01-05 M & F NON 185,594.41 209,127.68 159,361.36 180,723.50 190,372.88 197,240.02 0.00 0.00 0.00 0.00 0.00 0.00 1,122,419.85 101C TANF 06-13 M & F NON 193,161.74 230,842.03 171,029.39 187,370.05 203,891.38 201,887.83 0.00 0.00 0.00 0.00 0.00 0.00 1,188,182.42 101D TANF 14-20 MALE NON- 116,861.71 145,619.63 97,775.96 107,660.19 113,878.95 126,750.61 0.00 0.00 0.00 0.00 0.00 0.00 708,547.05 101E TANF 14-20 FEMALE NO 203,498.27 245,770.32 184,780.52 204,145.72 189,881.06 202,747.22 0.00 0.00 0.00 0.00 0.00 0.00 1,230,823.11 101F TANF 21-44 MALE NON- 169,066.80 186,332.54 139,906.53 153,541.13 154,912.92 178,412.65 0.00 0.00 0.00 0.00 0.00 0.00 982,172.57 101G TANF 21-44 FEMALE NO 675,010.64 762,852.95 569,850.73 601,026.19 623,028.74 655,838.72 0.00 0.00 0.00 0.00 0.00 0.00 3,887,607.97 101H TANF 44-64 M & F NON 172,588.82 210,896.33 129,249.10 144,831.99 153,151.64 172,650.05 0.00 0.00 0.00 0.00 0.00 0.00 983,367.93 101J TANF 65+ N & F NON-M 386.70 1,755.10 639.14 1,026.64 0.00 46.46 0.00 0.00 0.00 0.00 0.00 0.00 3,854.04 1026 TANF 21-44 MALE WITH 459.16 459.16 687.36 703.36 255.70 348.34 0.00 0.00 0.00 0.00 0.00 0.00 2,913.08 1027 TANF 21-44 FEMALE WI 2,234.54 1,642.75 1,879.09 1,636.16 1,851.61 1,618.68 0.00 0.00 0.00 0.00 0.00 0.00 10,862.83 1028 TANF 45-64 M & F WIT 2,666.01 3,029.39 3,411.96 2,816.45 2,806.01 3,198.54 0.00 0.00 0.00 0.00 0.00 0.00 17,928.36 1029 TANF 65+ M & F WITH 0.00 0.00 0.00 0.00 340.01 340.01 0.00 0.00 0.00 0.00 0.00 0.00 680.02 102F TANF 21-44 MALE WITH 0.00 0.00 0.00 0.00 0.00 57.97 0.00 0.00 0.00 0.00 0.00 0.00 57.97 102G TANF 21-44 FEMALE WI 114.14 0.00 148.98 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 263.12 2100 SSI AGED WITH MEDICA 517,424.68 511,239.64 504,412.65 540,081.44 543,680.99 546,864.77 0.00 0.00 0.00 0.00 0.00 0.00 3,163,704.17 11 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 ACUTE CAPITATION - AMOUNTS 210Z SSI AGED WITH MEDICA 49,877.76 41,039.73 22,081.91 23,413.54 21,605.57 28,528.68 0.00 0.00 0.00 0.00 0.00 0.00 186,547.19 2110 SSI AGED NON-MEDICAR 3,642,062.48 3,619,124.29 3,607,498.15 3,702,582.91 3,689,786.85 3,664,467.92 0.00 0.00 0.00 0.00 0.00 0.00 21,925,522.60 211Z SSI AGED NON-MEDICAR 78,228.86 86,121.22 72,367.88 82,693.05 81,900.02 86,554.35 0.00 0.00 0.00 0.00 0.00 0.00 487,865.38 2120 SSI AGED WITH QMB 2,450,128.66 2,473,631.98 2,476,928.12 2,626,796.19 2,618,090.03 2,617,252.70 0.00 0.00 0.00 0.00 0.00 0.00 15,262,827.68 212Z SSI AGED WITH QMB PP 13,620.61 13,486.63 9,335.42 11,520.05 10,119.16 11,262.06 0.00 0.00 0.00 0.00 0.00 0.00 69,343.93 2200 SSI DISABLED WITH ME 436,041.82 439,027.36 439,230.09 471,982.70 472,337.19 481,746.84 0.00 0.00 0.00 0.00 0.00 0.00 2,740,366.00 220Z SSI DISABLED WITH ME 60,328.84 53,118.37 35,014.97 40,775.15 30,176.20 36,098.28 0.00 0.00 0.00 0.00 0.00 0.00 255,511.81 2210 SSI DISABLED NON-MED 39,098,075.71 39,278,773.52 39,494,487.91 41,108,076.70 41,225,709.73 41,416,680.96 0.00 0.00 0.00 0.00 0.00 0.00 241,621,804.53 221Z SSI DISABLED NON-MED 905,477.22 935,481.04 918,214.05 836,277.81 835,299.21 881,002.95 0.00 0.00 0.00 0.00 0.00 0.00 5,311,752.28 2220 SSI DISABLED WITH QM 3,286,411.17 3,316,754.92 3,341,589.73 3,521,559.66 3,544,533.98 3,561,434.59 0.00 0.00 0.00 0.00 0.00 0.00 20,572,284.05 222Z SSI DISABLED WITH QM 4,052.86 6,619.25 5,377.18 3,236.55 2,377.94 4,789.18 0.00 0.00 0.00 0.00 0.00 0.00 26,452.96 2300 SSI BLIND WITH MEDIC 2,473.77 2,529.04 2,582.99 2,830.52 2,970.48 3,035.95 0.00 0.00 0.00 0.00 0.00 0.00 16,422.75 230Z SSI BLIND WITH MEDIC 0.00 854.74 18.73 0.00 0.00 136.83 0.00 0.00 0.00 0.00 0.00 0.00 1,010.30 2310 SSI BLIND NON-MEDICA 275,071.09 276,294.24 280,960.75 290,115.63 287,531.05 291,399.85 0.00 0.00 0.00 0.00 0.00 0.00 1,701,372.61 231Z SSI BLIND NON-MEDICA 8,913.22 4,298.33 901.83 1,014.17 5,158.95 5,812.43 0.00 0.00 0.00 0.00 0.00 0.00 26,098.93 2320 SSI BLIND WITH QMB 27,410.74 27,253.01 27,030.42 29,444.70 29,406.12 29,412.46 0.00 0.00 0.00 0.00 0.00 0.00 169,957.45 232Z SSI BLIND WITH QMB P 0.00 7.86 40.59 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 48.45 4303 SOBRA CHILD 06-13 M 104.41 104.41 104.41 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 313.23 4304 SOBRA CHILD 14-20 MA 132.27 132.27 132.27 133.82 133.82 133.82 0.00 0.00 0.00 0.00 0.00 0.00 798.27 4305 SOBRA CHILD 14-20 FE 0.00 0.00 0.00 235.50 454.24 454.24 0.00 0.00 0.00 0.00 0.00 0.00 1,143.98 4311 SOBRA CHILD <1 M & F 14,984,943.93 15,071,699.59 14,923,681.78 15,805,371.91 15,681,964.08 15,708,497.27 0.00 0.00 0.00 0.00 0.00 0.00 92,176,158.56 4312 SOBRA CHILD 01-05 M 10,028,810.89 10,127,192.94 9,999,598.45 10,270,667.15 10,141,005.07 10,050,286.93 0.00 0.00 0.00 0.00 0.00 0.00 60,617,561.43 4313 SOBRA CHILD 06-13 M 12,092,099.25 12,235,938.72 12,161,428.16 12,553,972.05 12,491,512.51 12,433,828.92 0.00 0.00 0.00 0.00 0.00 0.00 73,968,779.61 4314 SOBRA CHILD 14-20 MA 4,320,791.44 4,370,768.52 4,327,896.88 4,366,947.45 4,334,627.47 4,305,103.65 0.00 0.00 0.00 0.00 0.00 0.00 26,026,135.41 4315 SOBRA CHILD 14-20 FE 6,611,351.80 6,712,363.31 6,643,910.30 6,672,739.14 6,618,535.18 6,561,743.32 0.00 0.00 0.00 0.00 0.00 0.00 39,820,643.05 431A SOBRA CHILD < 1 M & 538,328.21 682,638.80 481,416.75 515,400.24 542,950.47 550,150.11 0.00 0.00 0.00 0.00 0.00 0.00 3,310,884.58 431B SOBRA CHILD 01-05 M 277,266.28 299,519.39 206,180.13 234,941.75 264,117.13 277,618.77 0.00 0.00 0.00 0.00 0.00 0.00 1,559,643.45 431C SOBRA CHILD 6-13 M&F 258,266.43 298,430.48 211,803.88 230,004.05 234,189.21 237,456.72 0.00 0.00 0.00 0.00 0.00 0.00 1,470,150.77 431D SOBRA CHILD 14-20 MA 197,126.97 237,971.81 175,129.51 184,830.23 185,750.23 175,611.73 0.00 0.00 0.00 0.00 0.00 0.00 1,156,420.48 431E SOBRA CHILD 14-20 FE 246,489.14 300,293.23 205,760.34 217,606.81 222,616.15 210,978.59 0.00 0.00 0.00 0.00 0.00 0.00 1,403,744.26 5007 SOBRA PREG 21-44 FEM 13,465.38 14,451.01 13,476.95 14,096.90 13,039.16 14,170.66 0.00 0.00 0.00 0.00 0.00 0.00 82,700.06 5008 SOBRA PREG 45-64 FEM 0.00 0.00 0.00 0.00 760.16 348.44 0.00 0.00 0.00 0.00 0.00 0.00 1,108.60 500G SOBRA PREG 21-44 FEM 342.47 1,249.48 107.55 1,142.12 1,080.03 403.56 0.00 0.00 0.00 0.00 0.00 0.00 4,325.21 5013 SOBRA PREG 09-13 FEM 236.10 192.22 93.48 141.56 93.11 38.07 0.00 0.00 0.00 0.00 0.00 0.00 794.54 5015 SOBRA PREG 14-20 FEM 872,827.32 908,923.38 875,384.17 874,719.53 834,157.68 795,443.41 0.00 0.00 0.00 0.00 0.00 0.00 5,161,455.49 5017 SOBRA PREG 21-44 FEM 2,487,935.39 2,570,888.72 2,552,498.51 2,564,948.80 2,488,265.99 2,400,811.31 0.00 0.00 0.00 0.00 0.00 0.00 15,065,348.72 5018 SOBRA PREG 45-64 FEM 6,675.42 7,913.95 8,542.21 9,983.67 7,529.04 7,775.66 0.00 0.00 0.00 0.00 0.00 0.00 48,419.95 501C SOBRA PREG 09-13 FEM 46.68 1.98 0.00 31.61 0.00 94.83 0.00 0.00 0.00 0.00 0.00 0.00 175.10 12 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 ACUTE CAPITATION - AMOUNTS 501E SOBRA PREG 14-20 FEM 95,533.54 106,173.39 78,527.72 76,684.25 79,869.36 85,570.07 0.00 0.00 0.00 0.00 0.00 0.00 522,358.33 501G SOBRA PREG 21-44 FEM 285,412.40 308,231.54 224,099.42 226,074.90 232,896.14 254,529.93 0.00 0.00 0.00 0.00 0.00 0.00 1,531,244.33 501H SOBRA PREG 45-64 FEM 1,292.93 1,753.90 499.31 26.98 592.87 1,625.41 0.00 0.00 0.00 0.00 0.00 0.00 5,791.40 5027 SOBRA PREG 21-44 FEM 646.65 400.96 459.98 0.00 0.00 415.96 0.00 0.00 0.00 0.00 0.00 0.00 1,923.55 502G SOBRA PREG 21-44 FEM 0.00 48.06 0.00 0.00 0.00 53.28 0.00 0.00 0.00 0.00 0.00 0.00 101.34 5500 SOBRA FPS FEMALE WIT 14.79 14.79 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 29.58 5510 SOBRA FPS FEMALE WIT 55,831.36 55,597.33 57,883.20 56,378.76 58,714.70 60,571.35 0.00 0.00 0.00 0.00 0.00 0.00 344,976.70 172,437,717.37 174,793,502.43 172,886,276.96 178,521,147.89 177,824,807.33 SUBTOTAL: 177,887,885.74 0.00 0.00 0.00 0.00 0.00 0.00 1,054,351,337.72 9910 TANF & SOBRA CHILDRE 6,036,364.92 6,869,320.76 5,885,184.02 6,684,603.19 6,198,200.11 6,135,633.60 0.00 0.00 0.00 0.00 0.00 0.00 37,809,306.60 9920 SSI W/MEDICARE KICK 58,173.94 63,849.25 46,556.52 54,941.44 49,707.35 73,971.25 0.00 0.00 0.00 0.00 0.00 0.00 347,199.75 9921 SSI W/O MEDICARE KIC 239,924.06 134,265.05 192,071.15 333,799.21 263,267.01 243,302.65 0.00 0.00 0.00 0.00 0.00 0.00 1,406,629.13 9950 S.O.B.R.A. KICK PAYM 11,148,663.30 11,914,341.84 11,384,743.30 12,524,797.84 11,228,055.61 11,394,310.83 0.00 0.00 0.00 0.00 0.00 0.00 69,594,912.72 SUBTOTAL: 17,483,126.22 18,981,776.90 17,508,554.99 19,598,141.68 17,739,230.08 17,847,218.33 0.00 0.00 0.00 0.00 0.00 0.00 109,158,048.20 3100 TRANSPLANT OPTION 1 33.00 33.00 7.98 46.84 82.50 66.00 0.00 0.00 0.00 0.00 0.00 0.00 269.32 310Z TRANSPLANT OPTION 1 0.00 0.00 0.00 101.66 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 101.66 SUBTOTAL: 33.00 33.00 7.98 148.50 82.50 66.00 0.00 0.00 0.00 0.00 0.00 0.00 370.98 1106 TANF EXPANDED 21-44 111,176.00 111,701.00 111,232.83 112,734.76 113,399.71 112,099.96 0.00 0.00 0.00 0.00 0.00 0.00 672,344.26 1107 TANF EXPANDED 21-44 371,722.03 378,930.51 375,180.33 376,153.76 377,527.59 380,054.60 0.00 0.00 0.00 0.00 0.00 0.00 2,259,568.82 1108 TANF EXPANDED 45-64 747,373.80 769,963.19 766,800.84 810,616.56 817,146.39 816,092.39 0.00 0.00 0.00 0.00 0.00 0.00 4,727,993.17 1109 TANF EXPANDED 65+ M& 201,780.57 204,164.26 204,250.59 217,456.86 216,993.31 221,696.55 0.00 0.00 0.00 0.00 0.00 0.00 1,266,342.14 110F TANF EXPANDED 21-44 1,975.53 2,180.22 2,446.15 2,505.29 3,466.91 3,762.48 0.00 0.00 0.00 0.00 0.00 0.00 16,336.58 110G TANF EXPANDED 21-44 6,710.50 12,081.34 6,740.55 4,655.79 8,640.26 7,398.59 0.00 0.00 0.00 0.00 0.00 0.00 46,227.03 110H TANF EXPANDED 45-64 13,496.93 16,609.32 10,395.48 14,933.34 11,354.90 12,563.97 0.00 0.00 0.00 0.00 0.00 0.00 79,353.94 110J TANF EXPANDED 65+ M& 1,020.53 4,553.94 1,307.36 3,644.92 3,302.03 3,486.71 0.00 0.00 0.00 0.00 0.00 0.00 17,315.49 1111 TANF EXPANDED <1 M&F 16,028.40 14,008.29 14,179.82 14,648.70 12,730.11 12,696.21 0.00 0.00 0.00 0.00 0.00 0.00 84,291.53 1112 TANF EXPANDED 01-05 100,923.44 102,108.10 100,608.80 104,127.07 104,431.13 100,377.10 0.00 0.00 0.00 0.00 0.00 0.00 612,575.64 1113 TANF EXPANDED 06-13 351,786.16 355,809.55 359,898.10 373,886.98 375,793.14 379,140.70 0.00 0.00 0.00 0.00 0.00 0.00 2,196,314.63 1114 TANF EXPANDED 14-20 245,957.73 244,644.48 239,634.75 242,297.59 241,861.84 241,697.86 0.00 0.00 0.00 0.00 0.00 0.00 1,456,094.25 1115 TANF EXPANDED 14-20 703,518.73 714,244.70 701,237.71 698,032.68 699,656.94 694,735.32 0.00 0.00 0.00 0.00 0.00 0.00 4,211,426.08 1116 TANF EXPANDED 21-44 3,703,188.98 3,744,084.91 3,681,536.78 3,696,658.61 3,639,619.78 3,603,423.84 0.00 0.00 0.00 0.00 0.00 0.00 22,068,512.90 1117 TANF EXPANDED 21-44 12,016,169.81 12,188,467.39 12,004,385.00 12,062,515.02 11,982,089.26 11,974,754.71 0.00 0.00 0.00 0.00 0.00 0.00 72,228,381.19 1118 TANF EXPANDED 45-64 6,286,516.59 6,343,625.04 6,309,495.27 6,635,210.48 6,633,615.02 6,568,824.05 0.00 0.00 0.00 0.00 0.00 0.00 38,777,286.45 1119 TANF EXPANDED 65+ M& 17,317.09 14,998.89 16,886.97 14,302.40 12,838.70 14,065.94 0.00 0.00 0.00 0.00 0.00 0.00 90,409.99 111A TANF EXPANDED <1 M&F 6,357.68 4,868.80 808.57 1,242.67 2,798.45 2,376.01 0.00 0.00 0.00 0.00 0.00 0.00 18,452.18 111B TANF EXPANDED 01-05 3,385.38 2,644.84 1,758.76 2,857.93 1,765.94 3,016.79 0.00 0.00 0.00 0.00 0.00 0.00 15,429.64 111C TANF EXPANDED 06-13 9,508.35 9,391.23 5,759.12 7,347.76 6,676.80 6,056.13 0.00 0.00 0.00 0.00 0.00 0.00 44,739.39 111D TANF EXPANDED 14-20 15,860.31 17,993.36 14,188.22 12,468.73 15,448.95 14,849.45 0.00 0.00 0.00 0.00 0.00 0.00 90,809.02 13 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 ACUTE CAPITATION - AMOUNTS 111E TANF EXPANDED 14-20 34,611.27 39,562.47 30,344.81 30,694.99 27,061.05 29,068.30 0.00 0.00 0.00 0.00 0.00 0.00 191,342.89 111F TANF EXPANDED 21-44 211,539.11 240,316.84 170,286.57 191,270.95 192,351.82 218,832.95 0.00 0.00 0.00 0.00 0.00 0.00 1,224,598.24 111G TANF EXPANDED 21-44 500,111.29 605,565.18 423,263.75 457,875.62 471,240.87 485,932.30 0.00 0.00 0.00 0.00 0.00 0.00 2,943,989.01 111H TANF EXPANDED 45-64 236,076.14 277,343.36 211,141.38 214,303.01 212,148.56 197,405.14 0.00 0.00 0.00 0.00 0.00 0.00 1,348,417.59 111J TANF EXPANDED 65+ M& 1,723.19 2,205.78 2,643.93 459.00 940.14 2,003.58 0.00 0.00 0.00 0.00 0.00 0.00 9,975.62 1126 TANF EXPANDED 21-44 4,722.29 4,495.32 4,768.94 4,614.84 4,565.26 4,972.05 0.00 0.00 0.00 0.00 0.00 0.00 28,138.70 1127 TANF EXPANDED 21-44 15,206.49 15,067.78 14,482.45 14,954.18 14,789.29 13,613.29 0.00 0.00 0.00 0.00 0.00 0.00 88,113.48 1128 TANF EXPANDED 45-64 42,367.84 44,499.45 44,500.67 45,048.22 43,248.07 45,498.91 0.00 0.00 0.00 0.00 0.00 0.00 265,163.16 1129 TANF EXPANDED 65+ M& 14,384.12 14,435.59 12,832.27 15,104.02 14,362.32 16,231.15 0.00 0.00 0.00 0.00 0.00 0.00 87,349.47 112F TANF EXPANDED 21-44 125.65 34.24 70.76 160.74 0.00 36.89 0.00 0.00 0.00 0.00 0.00 0.00 428.28 112G TANF EXPANDED 21-44 439.18 169.74 43.45 292.37 244.77 332.04 0.00 0.00 0.00 0.00 0.00 0.00 1,521.55 112H TANF EXPANDED 45-64 352.02 1,405.97 761.43 0.00 439.42 61.79 0.00 0.00 0.00 0.00 0.00 0.00 3,020.63 2400 SSI AGED EXPANDED WI 42,731.13 48,808.07 40,991.83 46,805.06 51,282.72 47,466.59 0.00 0.00 0.00 0.00 0.00 0.00 278,085.40 240Z SSI AGED EXPANDED WI 50,184.82 48,389.51 30,529.88 28,284.62 25,885.00 22,204.29 0.00 0.00 0.00 0.00 0.00 0.00 205,478.12 2410 SSI AGED EXPANDED NO 958,476.59 942,870.18 890,182.74 896,916.91 886,247.55 842,470.86 0.00 0.00 0.00 0.00 0.00 0.00 5,417,164.83 241Z SSI AGED EXPANDED NO 27,951.85 27,650.02 22,348.38 30,227.42 25,585.39 27,384.63 0.00 0.00 0.00 0.00 0.00 0.00 161,147.69 2420 SSI AGED EXPANDED WI 2,590,938.69 2,608,109.39 2,618,095.52 2,755,058.05 2,752,204.36 2,771,704.07 0.00 0.00 0.00 0.00 0.00 0.00 16,096,110.08 242Z SSI AGED EXPANDED WI 22,429.25 21,222.86 15,253.06 21,585.29 15,016.80 18,722.26 0.00 0.00 0.00 0.00 0.00 0.00 114,229.52 2520 SSI BLIND EXPANDED W 992.19 1,254.30 1,261.89 1,459.86 1,459.86 1,459.86 0.00 0.00 0.00 0.00 0.00 0.00 7,887.96 252Z SSI BLIND EXPANDED W 0.00 7.06 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 7.06 2600 SSI DISABLED EXPANDE 63,324.49 64,667.69 65,361.69 66,841.71 69,167.57 67,230.10 0.00 0.00 0.00 0.00 0.00 0.00 396,593.25 260Z SSI DISABLED EXPANDE 48,040.34 44,118.56 31,304.77 28,142.63 29,122.22 22,783.68 0.00 0.00 0.00 0.00 0.00 0.00 203,512.20 2610 SSI DISABLED EXPANDE 3,169,914.42 3,090,994.97 2,942,752.65 2,856,547.32 2,767,763.28 2,628,199.58 0.00 0.00 0.00 0.00 0.00 0.00 17,456,172.22 261Z SSI DISABLED EXPANDE 52,209.17 55,417.91 42,593.41 43,730.07 54,957.08 47,437.77 0.00 0.00 0.00 0.00 0.00 0.00 296,345.41 2620 SSI DISABLED EXPANDE 960,450.36 983,446.68 1,007,025.10 1,079,992.40 1,098,870.81 1,118,375.75 0.00 0.00 0.00 0.00 0.00 0.00 6,248,161.10 262Z SSI DISABLED EXPANDE 6,001.22 6,573.29 4,935.68 6,534.11 3,576.55 2,046.86 0.00 0.00 0.00 0.00 0.00 0.00 29,667.71 33,987,077.65 34,445,705.57 33,556,509.01 34,245,201.29 SUBTOTAL: 34,043,687.92 33,804,644.05 0.00 0.00 0.00 0.00 0.00 0.00 204,082,825.49 9911 SB PAYMENT FOR TANF 402,419.02 464,961.55 324,818.42 340,437.77 343,301.41 378,183.06 0.00 0.00 0.00 0.00 0.00 0.00 2,254,121.23 9922 SB PAYMENT FOR SSI E 11,633.48 11,228.08 5,838.94 0.00 11,800.88 6,167.47 0.00 0.00 0.00 0.00 0.00 0.00 46,668.85 9923 SB PAYMENT FOR SSI E 29,604.21 28,713.64 23,831.47 30,340.10 24,026.64 12,334.94 0.00 0.00 0.00 0.00 0.00 0.00 148,851.00 SUBTOTAL: 443,656.71 504,903.27 354,488.83 370,777.87 379,128.93 396,685.47 0.00 0.00 0.00 0.00 0.00 0.00 2,449,641.08 3306 AHC CARE MALE 21-44 2,533.72 2,152.79 2,152.79 1,743.03 2,159.44 2,159.44 0.00 0.00 0.00 0.00 0.00 0.00 12,901.21 3307 AHC CARE FEMALE 21-4 1,262.03 829.78 440.20 449.44 830.51 449.44 0.00 0.00 0.00 0.00 0.00 0.00 4,261.40 3308 AHC CARE M&F 45-64 W 5,063.45 5,587.30 5,241.71 5,354.33 5,354.33 4,972.95 0.00 0.00 0.00 0.00 0.00 0.00 31,574.07 3309 AHC CARE M&F 65+ W/ 3,725.65 4,196.91 4,071.24 4,468.88 4,468.88 4,119.58 0.00 0.00 0.00 0.00 0.00 0.00 25,051.14 330G AHC CARE FEMALE 21-4 0.00 0.00 0.00 0.00 1,127.39 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,127.39 330J AHC CARE M&F 65+ W/ 0.00 1,743.11 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,743.11 14 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 ACUTE CAPITATION - AMOUNTS 3314 AHC CARE MALE 14-20 409,536.65 395,081.23 381,542.71 371,741.50 367,078.06 365,462.88 0.00 0.00 0.00 0.00 0.00 0.00 2,290,443.03 3315 AHC CARE FEMALE 14-2 509,577.91 488,841.18 482,074.37 469,641.08 477,638.70 466,501.21 0.00 0.00 0.00 0.00 0.00 0.00 2,894,274.45 3316 AHC CARE MALE 21-44 1,839,320.23 1,703,301.06 1,533,437.90 1,437,292.40 1,363,456.62 1,303,241.73 0.00 0.00 0.00 0.00 0.00 0.00 9,180,049.94 3317 AHC CARE FEMALE 21-4 1,905,878.09 1,783,456.26 1,609,842.59 1,524,009.39 1,455,853.26 1,382,014.20 0.00 0.00 0.00 0.00 0.00 0.00 9,661,053.79 3318 AHC CARE M&F 45-64 N 5,404,381.66 5,165,385.30 4,895,002.07 4,747,676.26 4,563,511.54 4,400,933.55 0.00 0.00 0.00 0.00 0.00 0.00 29,176,890.38 3319 AHC CARE M&F 65+ NO 0.00 0.00 0.00 0.00 0.00 414.49 0.00 0.00 0.00 0.00 0.00 0.00 414.49 331A AHC CARE M&F < 1 NO 0.00 0.00 0.00 254.49 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 254.49 331D AHC CARE MALE 14-20 3,661.11 6,269.23 4,574.73 6,803.77 3,257.48 8,225.24 0.00 0.00 0.00 0.00 0.00 0.00 32,791.56 331E AHC CARE FEMALE 14-2 6,922.86 10,011.27 10,246.13 7,182.04 5,011.49 3,938.86 0.00 0.00 0.00 0.00 0.00 0.00 43,312.65 331F AHC CARE MALE 21-44 21,036.83 14,713.01 8,036.69 15,472.29 9,453.12 6,148.15 0.00 0.00 0.00 0.00 0.00 0.00 74,860.09 331G AHC CARE FEMALE 21-4 14,657.23 26,667.61 11,073.50 10,257.18 7,211.57 10,135.87 0.00 0.00 0.00 0.00 0.00 0.00 80,002.96 331H AHC CARE M&F 45-64 N 43,548.23 39,317.17 26,663.46 43,018.76 14,400.54 17,670.51 0.00 0.00 0.00 0.00 0.00 0.00 184,618.67 331J AHC CARE M&F 65+ NO 0.00 0.00 0.00 3,053.88 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 3,053.88 3326 AHC CARE MALE 21-44 2,308.94 2,308.94 2,308.94 2,283.12 2,697.61 2,697.61 0.00 0.00 0.00 0.00 0.00 0.00 14,605.16 3327 AHC CARE FEMALE 21-4 691.18 691.18 697.88 329.81 769.36 769.36 0.00 0.00 0.00 0.00 0.00 0.00 3,948.77 3328 AHC CARE M&F 45-64 W 4,889.63 4,889.63 6,512.37 6,923.12 7,286.16 6,896.81 0.00 0.00 0.00 0.00 0.00 0.00 37,397.72 3329 AHC CARE M&F 65+ W/ 872.45 -1,108.45 821.83 842.00 842.00 842.00 0.00 0.00 0.00 0.00 0.00 0.00 3,111.83 10,179,867.85 9,654,334.51 SUBTOTAL: 8,984,741.11 8,658,796.77 8,292,408.06 7,987,593.88 0.00 0.00 0.00 0.00 0.00 0.00 53,757,742.18 9933 SB PAYMENT FOR AHCCS 52,056.26 34,049.36 40,717.58 24,142.37 36,391.73 35,621.16 0.00 0.00 0.00 0.00 0.00 0.00 222,978.46 SUBTOTAL: 52,056.26 34,049.36 40,717.58 24,142.37 36,391.73 35,621.16 0.00 0.00 0.00 0.00 0.00 0.00 222,978.46 3606 AHC CARE/MI MALE 21- 2,232.19 3,045.37 1,944.56 2,842.24 2,744.21 2,744.21 0.00 0.00 0.00 0.00 0.00 0.00 15,552.78 3607 AHC CARE/MI FEMALE 2 847.77 847.77 407.89 414.49 854.04 854.04 0.00 0.00 0.00 0.00 0.00 0.00 4,226.00 3608 AHC CARE/MI M&F 45-6 3,315.87 3,176.43 2,593.80 4,147.84 4,412.33 4,492.95 0.00 0.00 0.00 0.00 0.00 0.00 22,139.22 360F AHC CARE/MI MALE 21- 0.00 2,290.41 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2,290.41 360H AHC CARE/MI M&F 45-6 0.00 4,162.14 0.00 0.00 0.00 492.56 0.00 0.00 0.00 0.00 0.00 0.00 4,654.70 3614 AHC CARE/MI MALE 14- 2,802,562.13 2,736,163.07 2,673,681.09 2,653,495.19 2,611,214.50 2,570,823.27 0.00 0.00 0.00 0.00 0.00 0.00 16,047,939.25 3615 AHC CARE/MI FEMALE 1 2,534,504.87 2,489,426.29 2,408,309.81 2,389,672.98 2,360,347.13 2,336,679.40 0.00 0.00 0.00 0.00 0.00 0.00 14,518,940.48 3616 AHC CARE/MI MALE 21- 7,008,942.61 6,576,717.62 6,177,395.83 5,908,812.41 5,628,237.16 5,355,283.44 0.00 0.00 0.00 0.00 0.00 0.00 36,655,389.07 3617 AHC CARE/MI FEMALE 2 4,580,327.13 4,347,656.71 4,087,452.63 3,939,900.70 3,775,615.87 3,602,003.47 0.00 0.00 0.00 0.00 0.00 0.00 24,332,956.51 3618 AHC CARE/MI M&F 45-6 11,992,659.38 11,598,170.61 11,176,323.13 10,907,114.85 10,580,368.03 10,245,488.36 0.00 0.00 0.00 0.00 0.00 0.00 66,500,124.36 3619 AHC CARE/MI M&F 65+ 407.89 407.89 407.89 414.49 414.49 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2,052.65 361D AHC CARE/MI MALE 14- 31,100.75 28,087.65 21,661.87 26,471.17 33,280.03 28,947.01 0.00 0.00 0.00 0.00 0.00 0.00 169,548.48 361E AHC CARE/MI FEMALE 1 29,587.70 47,453.01 25,089.87 28,444.17 19,314.21 34,902.45 0.00 0.00 0.00 0.00 0.00 0.00 184,791.41 361F AHC CARE/MI MALE 21- 54,151.33 49,463.90 45,237.54 57,589.44 29,046.58 57,693.23 0.00 0.00 0.00 0.00 0.00 0.00 293,182.02 361G AHC CARE/MI FEMALE 2 37,475.21 33,533.51 31,461.20 27,848.17 30,775.61 26,660.40 0.00 0.00 0.00 0.00 0.00 0.00 187,754.10 361H AHC CARE/MI M&F 45-6 77,132.83 72,579.04 60,178.66 74,207.92 45,901.40 67,945.85 0.00 0.00 0.00 0.00 0.00 0.00 397,945.70 361J AHC CARE/MI M&F 65+ 0.00 0.00 0.00 0.00 3,817.35 0.00 0.00 0.00 0.00 0.00 0.00 0.00 3,817.35 15 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 ACUTE CAPITATION - AMOUNTS 3626 AHC CARE/MI MALE 21- 722.90 722.90 722.90 341.43 341.43 341.43 0.00 0.00 0.00 0.00 0.00 0.00 3,192.99 3628 AHC CARE/MI M&F 45-6 0.00 0.00 0.00 0.00 0.00 386.47 0.00 0.00 0.00 0.00 0.00 0.00 386.47 29,155,970.56 27,993,904.32 26,712,868.67 26,021,717.49 SUBTOTAL: 25,126,684.37 24,335,738.54 0.00 0.00 0.00 0.00 0.00 0.00 159,346,883.95 9936 SB PAYMENT FOR AHC C 151,524.24 156,655.41 115,331.98 91,090.11 136,321.39 128,782.25 0.00 0.00 0.00 0.00 0.00 0.00 779,705.38 SUBTOTAL: 151,524.24 156,655.41 115,331.98 91,090.11 136,321.39 128,782.25 0.00 0.00 0.00 0.00 0.00 0.00 779,705.38 4517 BC PATIENT FEMALE 21 3,687.33 3,478.64 3,289.61 3,423.05 3,492.39 4,241.85 0.00 0.00 0.00 0.00 0.00 0.00 21,612.87 4518 BC PATIENT FEMALE 45 64,074.13 66,932.17 71,769.05 80,660.43 79,674.01 83,116.55 0.00 0.00 0.00 0.00 0.00 0.00 446,226.34 4519 BC PATIENT FEMALE 65 0.00 0.00 0.00 0.00 0.00 411.72 0.00 0.00 0.00 0.00 0.00 0.00 411.72 451G BC PATIENT FEMALE 21 0.00 229.30 391.98 140.17 1,054.27 417.43 0.00 0.00 0.00 0.00 0.00 0.00 2,233.15 451H BC PATIENT FEMALE 45 2,696.12 2,469.65 5,063.74 3,343.25 2,787.37 4,576.97 0.00 0.00 0.00 0.00 0.00 0.00 20,937.10 4617 CC PATIENT FEMALE 21 2,311.42 2,311.42 2,514.19 2,997.19 3,239.67 3,933.78 0.00 0.00 0.00 0.00 0.00 0.00 17,307.67 4618 CC PATIENT FEMALE 45 5,869.63 6,234.76 6,500.92 7,408.66 7,008.42 7,398.29 0.00 0.00 0.00 0.00 0.00 0.00 40,420.68 461G CC PATIENT FEMALE 21 0.00 0.00 364.02 620.18 432.41 748.47 0.00 0.00 0.00 0.00 0.00 0.00 2,165.08 461H CC PATIENT FEMALE 45 0.00 283.58 452.64 337.00 529.69 600.22 0.00 0.00 0.00 0.00 0.00 0.00 2,203.13 SUBTOTAL: 78,638.63 81,939.52 90,346.15 98,929.93 98,218.23 105,445.28 0.00 0.00 0.00 0.00 0.00 0.00 553,517.74 8600 SSI BLIND FREEDOM/WO 162.06 162.06 162.06 173.68 173.68 173.68 0.00 0.00 0.00 0.00 0.00 0.00 1,007.22 8700 SSI DISABLED FREEDOM 168,352.24 168,660.16 168,276.17 178,885.20 176,585.57 174,041.93 0.00 0.00 0.00 0.00 0.00 0.00 1,034,801.27 870Z SSI DISABLED FREEDOM 5,449.65 2,441.25 4,189.98 4,234.71 2,389.96 2,974.87 0.00 0.00 0.00 0.00 0.00 0.00 21,680.42 8710 SSI DISABLED FREEDOM 147,930.07 148,608.25 139,185.70 141,394.72 141,275.84 140,177.77 0.00 0.00 0.00 0.00 0.00 0.00 858,572.35 871Z SSI DISABLED FREEDOM 14,731.60 6,195.43 10,798.40 20,192.51 16,401.10 10,324.64 0.00 0.00 0.00 0.00 0.00 0.00 78,643.68 8720 SSI DISABLED FREEDOM 22,377.66 22,024.84 22,018.55 21,366.57 20,960.85 22,469.84 0.00 0.00 0.00 0.00 0.00 0.00 131,218.31 872Z SSI DISABLED FREEDOM 1,274.50 1,139.34 487.12 239.06 792.66 136.83 0.00 0.00 0.00 0.00 0.00 0.00 4,069.51 SUBTOTAL: 360,277.78 349,231.33 345,117.98 366,486.45 358,579.66 350,299.56 0.00 0.00 0.00 0.00 0.00 0.00 2,129,992.76 TOTAL: 264,329,946.27 266,996,035.62 260,594,961.24 267,996,580.35 264,035,540.20 262,879,980.26 0.00 0.00 0.00 0.00 0.00 0.00 1,586,833,043.94 16 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 ACUTE CAPITATION - MEMBER MONTHS 1002 TANF 01-05 M & F WIT 0.00 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 5.00 1003 TANF 06-13 M & F WIT 1.00 1.00 1.00 1.00 2.06 1.00 0.00 0.00 0.00 0.00 0.00 0.00 7.06 1004 TANF 14-20 MALE WITH 0.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 3.00 1005 TANF 14-20 FEMALE WI 1.00 4.00 4.00 5.00 4.00 3.00 0.00 0.00 0.00 0.00 0.00 0.00 21.00 1006 TANF 21-44 MALE WITH 116.06 101.28 104.20 115.47 114.82 119.28 0.00 0.00 0.00 0.00 0.00 0.00 671.11 1007 TANF 21-44 FEMALE WI 325.12 308.88 307.56 300.07 280.23 277.92 0.00 0.00 0.00 0.00 0.00 0.00 1,799.78 1008 TANF 45-64 M & F WIT 180.02 167.96 172.91 169.25 164.53 171.78 0.00 0.00 0.00 0.00 0.00 0.00 1,026.45 1009 TANF 65+ M & F WITH 38.94 34.87 35.56 41.87 43.82 44.87 0.00 0.00 0.00 0.00 0.00 0.00 239.93 100C TANF 06-13 M & F WIT 0.00 0.00 0.00 0.00 0.93 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.93 100F TANF 21-44 MALE WITH 1.89 1.66 7.31 1.32 1.16 1.70 0.00 0.00 0.00 0.00 0.00 0.00 15.04 100G TANF 21-44 FEMALE WI 12.64 7.12 6.35 2.87 11.78 9.62 0.00 0.00 0.00 0.00 0.00 0.00 50.38 100H TANF 44-64 M & F WIT 6.97 5.96 0.66 1.72 3.41 1.18 0.00 0.00 0.00 0.00 0.00 0.00 19.90 100J TANF 65+ M & F WITH 2.03 0.12 0.43 2.12 3.15 0.12 0.00 0.00 0.00 0.00 0.00 0.00 7.97 1011 TANF <1 M & F NON-ME 14,983.54 15,160.33 15,036.59 15,166.12 14,976.65 15,020.02 0.00 0.00 0.00 0.00 0.00 0.00 90,343.25 1012 TANF 01-05 M & F NON 88,434.87 89,049.72 88,102.92 87,516.72 86,701.90 86,131.65 0.00 0.00 0.00 0.00 0.00 0.00 525,937.78 1013 TANF 06-13 M & F NON 120,735.06 122,389.08 122,321.85 122,167.63 121,853.17 121,966.00 0.00 0.00 0.00 0.00 0.00 0.00 731,432.79 1014 TANF 14-20 MALE NON- 23,455.19 23,763.25 23,819.50 23,919.97 23,976.85 24,145.28 0.00 0.00 0.00 0.00 0.00 0.00 143,080.04 1015 TANF 14-20 FEMALE NO 29,152.23 29,477.86 29,416.24 29,537.89 29,504.07 29,657.31 0.00 0.00 0.00 0.00 0.00 0.00 176,745.60 1016 TANF 21-44 MALE NON- 21,655.48 21,936.03 21,839.58 21,738.89 21,447.09 21,313.33 0.00 0.00 0.00 0.00 0.00 0.00 129,930.40 1017 TANF 21-44 FEMALE NO 85,706.64 87,043.05 86,796.69 86,652.52 86,195.90 85,833.10 0.00 0.00 0.00 0.00 0.00 0.00 518,227.90 1018 TANF 45-64 M & F NON 16,448.32 16,693.92 16,655.11 16,574.48 16,534.31 16,569.57 0.00 0.00 0.00 0.00 0.00 0.00 99,475.71 1019 TANF 65+ M & F NON-M 48.61 54.72 47.73 50.41 43.00 38.74 0.00 0.00 0.00 0.00 0.00 0.00 283.21 101A TANF < 1 M & F NON-M 389.94 472.92 367.81 389.20 360.59 410.46 0.00 0.00 0.00 0.00 0.00 0.00 2,390.92 101B TANF 01-05 M & F NON 3,490.70 3,962.18 2,993.33 3,225.09 3,385.20 3,446.06 0.00 0.00 0.00 0.00 0.00 0.00 20,502.56 101C TANF 06-13 M & F NON 3,630.67 4,303.62 3,235.95 3,410.93 3,597.44 3,569.61 0.00 0.00 0.00 0.00 0.00 0.00 21,748.22 101D TANF 14-20 MALE NON- 789.44 988.14 664.47 700.31 724.55 810.90 0.00 0.00 0.00 0.00 0.00 0.00 4,677.81 101E TANF 14-20 FEMALE NO 1,104.13 1,332.55 997.08 1,094.58 1,008.58 1,083.52 0.00 0.00 0.00 0.00 0.00 0.00 6,620.44 101F TANF 21-44 MALE NON- 1,145.14 1,259.35 947.88 1,012.57 997.85 1,136.45 0.00 0.00 0.00 0.00 0.00 0.00 6,499.24 101G TANF 21-44 FEMALE NO 3,658.18 4,134.55 3,095.91 3,226.89 3,332.02 3,493.99 0.00 0.00 0.00 0.00 0.00 0.00 20,941.54 101H TANF 44-64 M & F NON 590.95 709.37 433.47 487.93 502.07 567.63 0.00 0.00 0.00 0.00 0.00 0.00 3,291.42 101J TANF 65+ N & F NON-M 1.44 6.05 2.12 3.56 0.00 0.12 0.00 0.00 0.00 0.00 0.00 0.00 13.29 1026 TANF 21-44 MALE WITH 3.00 3.00 5.00 5.00 2.00 2.64 0.00 0.00 0.00 0.00 0.00 0.00 20.64 1027 TANF 21-44 FEMALE WI 9.38 7.00 8.03 7.00 8.00 7.00 0.00 0.00 0.00 0.00 0.00 0.00 46.41 1028 TANF 45-64 M & F WIT 7.00 8.00 9.00 7.00 7.00 8.00 0.00 0.00 0.00 0.00 0.00 0.00 46.00 1029 TANF 65+ M & F WITH 0.00 0.00 0.00 0.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 2.00 102F TANF 21-44 MALE WITH 0.00 0.00 0.00 0.00 0.00 0.35 0.00 0.00 0.00 0.00 0.00 0.00 0.35 102G TANF 21-44 FEMALE WI 0.61 0.00 0.80 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1.41 2100 SSI AGED WITH MEDICA 3,814.65 3,772.57 3,720.42 3,766.47 3,794.26 3,822.44 0.00 0.00 0.00 0.00 0.00 0.00 22,690.81 17 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 ACUTE CAPITATION - MEMBER MONTHS 210Z SSI AGED WITH MEDICA 414.42 336.26 182.83 193.13 181.27 237.80 0.00 0.00 0.00 0.00 0.00 0.00 1,545.71 2110 SSI AGED NON-MEDICAR 5,152.65 5,118.28 5,103.31 5,066.87 5,049.22 5,006.86 0.00 0.00 0.00 0.00 0.00 0.00 30,497.19 211Z SSI AGED NON-MEDICAR 237.21 257.60 216.35 235.41 229.41 241.13 0.00 0.00 0.00 0.00 0.00 0.00 1,417.11 2120 SSI AGED WITH QMB 18,475.56 18,650.64 18,679.26 18,713.42 18,647.54 18,636.67 0.00 0.00 0.00 0.00 0.00 0.00 111,803.09 212Z SSI AGED WITH QMB PP 113.93 112.45 77.12 95.04 85.03 94.29 0.00 0.00 0.00 0.00 0.00 0.00 577.86 2200 SSI DISABLED WITH ME 3,257.52 3,281.85 3,281.54 3,357.42 3,366.66 3,441.21 0.00 0.00 0.00 0.00 0.00 0.00 19,986.20 220Z SSI DISABLED WITH ME 505.92 444.68 292.72 341.66 249.81 301.42 0.00 0.00 0.00 0.00 0.00 0.00 2,136.21 2210 SSI DISABLED NON-MED 54,957.00 55,212.04 55,517.56 55,955.25 56,125.40 56,379.05 0.00 0.00 0.00 0.00 0.00 0.00 334,146.30 221Z SSI DISABLED NON-MED 2,687.23 2,770.41 2,707.00 2,440.59 2,408.48 2,517.28 0.00 0.00 0.00 0.00 0.00 0.00 15,530.99 2220 SSI DISABLED WITH QM 24,787.12 25,011.13 25,193.27 25,288.04 25,443.51 25,562.58 0.00 0.00 0.00 0.00 0.00 0.00 151,285.65 222Z SSI DISABLED WITH QM 34.79 55.90 44.58 27.49 19.71 40.25 0.00 0.00 0.00 0.00 0.00 0.00 222.72 2300 SSI BLIND WITH MEDIC 18.00 18.25 18.83 18.93 19.60 19.87 0.00 0.00 0.00 0.00 0.00 0.00 113.48 230Z SSI BLIND WITH MEDIC 0.00 7.73 0.16 0.00 0.00 1.12 0.00 0.00 0.00 0.00 0.00 0.00 9.01 2310 SSI BLIND NON-MEDICA 389.19 390.85 397.58 397.22 393.42 398.82 0.00 0.00 0.00 0.00 0.00 0.00 2,367.08 231Z SSI BLIND NON-MEDICA 25.76 12.42 2.39 2.92 15.27 16.52 0.00 0.00 0.00 0.00 0.00 0.00 75.28 2320 SSI BLIND WITH QMB 202.83 201.93 200.64 207.00 205.90 206.12 0.00 0.00 0.00 0.00 0.00 0.00 1,224.42 232Z SSI BLIND WITH QMB P 0.00 0.06 0.33 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.39 4303 SOBRA CHILD 06-13 M 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 3.00 4304 SOBRA CHILD 14-20 MA 1.00 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 6.00 4305 SOBRA CHILD 14-20 FE 0.00 0.00 0.00 1.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 5.00 4311 SOBRA CHILD <1 M & F 32,495.25 32,689.55 32,376.91 33,075.97 32,805.17 32,854.07 0.00 0.00 0.00 0.00 0.00 0.00 196,296.92 4312 SOBRA CHILD 01-05 M 96,862.43 97,742.91 96,293.73 95,575.09 94,275.69 93,514.62 0.00 0.00 0.00 0.00 0.00 0.00 574,264.47 4313 SOBRA CHILD 06-13 M 117,841.23 119,196.55 118,355.24 118,062.42 117,438.12 116,888.48 0.00 0.00 0.00 0.00 0.00 0.00 707,782.04 4314 SOBRA CHILD 14-20 MA 30,352.47 30,711.51 30,393.88 30,075.62 29,822.85 29,595.57 0.00 0.00 0.00 0.00 0.00 0.00 180,951.90 4315 SOBRA CHILD 14-20 FE 29,683.83 30,137.42 29,834.51 29,631.83 29,385.58 29,137.69 0.00 0.00 0.00 0.00 0.00 0.00 177,810.86 431A SOBRA CHILD < 1 M & 611.20 771.58 547.03 563.97 579.43 587.61 0.00 0.00 0.00 0.00 0.00 0.00 3,660.82 431B SOBRA CHILD 01-05 M 4,719.41 5,249.11 3,577.30 3,965.19 4,360.04 4,408.17 0.00 0.00 0.00 0.00 0.00 0.00 26,279.22 431C SOBRA CHILD 6-13 M&F 4,491.81 5,191.36 3,593.19 3,870.96 3,955.43 3,970.88 0.00 0.00 0.00 0.00 0.00 0.00 25,073.63 431D SOBRA CHILD 14-20 MA 1,273.33 1,548.03 1,119.93 1,176.87 1,149.57 1,088.13 0.00 0.00 0.00 0.00 0.00 0.00 7,355.86 431E SOBRA CHILD 14-20 FE 1,319.53 1,608.71 1,077.59 1,143.63 1,145.81 1,106.42 0.00 0.00 0.00 0.00 0.00 0.00 7,401.69 5007 SOBRA PREG 21-44 FEM 59.89 64.74 61.29 62.79 57.75 62.70 0.00 0.00 0.00 0.00 0.00 0.00 369.16 5008 SOBRA PREG 45-64 FEM 0.00 0.00 0.00 0.00 2.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 3.00 500G SOBRA PREG 21-44 FEM 2.08 6.81 0.66 6.12 6.22 2.27 0.00 0.00 0.00 0.00 0.00 0.00 24.16 5013 SOBRA PREG 09-13 FEM 1.12 1.95 1.00 1.45 1.00 0.35 0.00 0.00 0.00 0.00 0.00 0.00 6.87 5015 SOBRA PREG 14-20 FEM 3,925.41 4,094.50 3,942.48 3,892.13 3,711.70 3,539.18 0.00 0.00 0.00 0.00 0.00 0.00 23,105.40 5017 SOBRA PREG 21-44 FEM 11,169.36 11,548.35 11,463.59 11,388.01 11,038.04 10,653.54 0.00 0.00 0.00 0.00 0.00 0.00 67,260.89 5018 SOBRA PREG 45-64 FEM 17.81 21.46 23.40 25.93 19.82 20.53 0.00 0.00 0.00 0.00 0.00 0.00 128.95 501C SOBRA PREG 09-13 FEM 0.87 0.03 0.00 0.54 0.00 1.64 0.00 0.00 0.00 0.00 0.00 0.00 3.08 18 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 ACUTE CAPITATION - MEMBER MONTHS 501E SOBRA PREG 14-20 FEM 519.26 576.32 428.79 414.59 426.98 453.35 0.00 0.00 0.00 0.00 0.00 0.00 2,819.29 501G SOBRA PREG 21-44 FEM 1,549.14 1,677.87 1,212.73 1,219.43 1,247.65 1,357.69 0.00 0.00 0.00 0.00 0.00 0.00 8,264.51 501H SOBRA PREG 45-64 FEM 4.14 6.10 1.60 0.06 2.16 4.44 0.00 0.00 0.00 0.00 0.00 0.00 18.50 5027 SOBRA PREG 21-44 FEM 3.00 1.74 2.00 0.00 0.00 1.67 0.00 0.00 0.00 0.00 0.00 0.00 8.41 502G SOBRA PREG 21-44 FEM 0.00 0.25 0.00 0.00 0.00 0.32 0.00 0.00 0.00 0.00 0.00 0.00 0.57 5500 SOBRA FPS FEMALE WIT 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2.00 5510 SOBRA FPS FEMALE WIT 3,934.86 3,916.00 4,075.98 3,984.08 4,149.44 4,278.27 0.00 0.00 0.00 0.00 0.00 0.00 24,338.63 872,040.40 885,810.44 SUBTOTAL: 871,459.76 871,782.92 867,608.07 866,299.22 0.00 0.00 0.00 0.00 0.00 0.00 5,235,000.81 9910 TANF & SOBRA CHILDRE 1,036.00 1,180.00 1,013.00 1,101.00 1,018.00 1,010.00 0.00 0.00 0.00 0.00 0.00 0.00 6,358.00 9920 SSI W/MEDICARE KICK 10.00 11.00 8.00 9.00 8.00 12.00 0.00 0.00 0.00 0.00 0.00 0.00 58.00 9921 SSI W/O MEDICARE KIC 41.00 23.00 33.00 55.00 43.00 40.00 0.00 0.00 0.00 0.00 0.00 0.00 235.00 9950 S.O.B.R.A. KICK PAYM 1,914.00 2,048.00 1,957.00 2,063.00 1,843.00 1,872.00 0.00 0.00 0.00 0.00 0.00 0.00 11,697.00 SUBTOTAL: 3,001.00 3,262.00 3,011.00 3,228.00 2,912.00 2,934.00 0.00 0.00 0.00 0.00 0.00 0.00 18,348.00 3100 TRANSPLANT OPTION 1 2.00 2.00 0.48 2.83 5.00 4.00 0.00 0.00 0.00 0.00 0.00 0.00 16.31 310Z TRANSPLANT OPTION 1 0.00 0.00 0.00 6.15 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 6.15 SUBTOTAL: 2.00 2.00 0.48 8.98 5.00 4.00 0.00 0.00 0.00 0.00 0.00 0.00 22.46 1106 TANF EXPANDED 21-44 779.83 782.94 779.79 773.20 777.72 767.74 0.00 0.00 0.00 0.00 0.00 0.00 4,661.22 1107 TANF EXPANDED 21-44 1,645.63 1,676.94 1,660.49 1,646.95 1,651.45 1,662.02 0.00 0.00 0.00 0.00 0.00 0.00 9,943.48 1108 TANF EXPANDED 45-64 2,056.13 2,118.89 2,111.49 2,109.83 2,129.86 2,125.27 0.00 0.00 0.00 0.00 0.00 0.00 12,651.47 1109 TANF EXPANDED 65+ M& 567.31 574.47 574.25 576.69 575.45 587.03 0.00 0.00 0.00 0.00 0.00 0.00 3,455.20 110F TANF EXPANDED 21-44 12.97 14.97 16.67 17.58 22.56 23.43 0.00 0.00 0.00 0.00 0.00 0.00 108.18 110G TANF EXPANDED 21-44 36.41 63.66 36.93 24.73 46.28 38.92 0.00 0.00 0.00 0.00 0.00 0.00 246.93 110H TANF EXPANDED 45-64 45.95 56.42 35.42 48.08 37.88 39.94 0.00 0.00 0.00 0.00 0.00 0.00 263.69 110J TANF EXPANDED 65+ M& 3.62 13.92 4.68 12.41 9.93 11.40 0.00 0.00 0.00 0.00 0.00 0.00 55.96 1111 TANF EXPANDED <1 M&F 33.89 29.55 30.09 29.68 25.76 25.88 0.00 0.00 0.00 0.00 0.00 0.00 174.85 1112 TANF EXPANDED 01-05 1,015.16 1,028.06 1,012.34 1,009.44 1,012.86 973.90 0.00 0.00 0.00 0.00 0.00 0.00 6,051.76 1113 TANF EXPANDED 06-13 3,527.91 3,568.22 3,609.81 3,621.41 3,638.08 3,668.29 0.00 0.00 0.00 0.00 0.00 0.00 21,633.72 1114 TANF EXPANDED 14-20 1,755.78 1,749.12 1,716.18 1,700.40 1,694.16 1,691.88 0.00 0.00 0.00 0.00 0.00 0.00 10,307.52 1115 TANF EXPANDED 14-20 3,153.92 3,207.24 3,150.07 3,103.37 3,107.01 3,078.49 0.00 0.00 0.00 0.00 0.00 0.00 18,800.10 1116 TANF EXPANDED 21-44 26,499.90 26,815.29 26,353.39 25,908.78 25,494.60 25,208.74 0.00 0.00 0.00 0.00 0.00 0.00 156,280.70 1117 TANF EXPANDED 21-44 53,965.59 54,770.40 53,939.36 53,635.10 53,279.04 53,218.95 0.00 0.00 0.00 0.00 0.00 0.00 322,808.44 1118 TANF EXPANDED 45-64 17,624.55 17,803.13 17,710.31 17,671.13 17,651.46 17,464.51 0.00 0.00 0.00 0.00 0.00 0.00 105,925.09 1119 TANF EXPANDED 65+ M& 49.23 41.77 48.01 38.32 34.23 37.72 0.00 0.00 0.00 0.00 0.00 0.00 249.28 111A TANF EXPANDED <1 M&F 7.04 5.40 0.89 1.28 2.81 2.46 0.00 0.00 0.00 0.00 0.00 0.00 19.88 111B TANF EXPANDED 01-05 63.20 50.13 32.65 51.09 31.63 53.02 0.00 0.00 0.00 0.00 0.00 0.00 281.72 111C TANF EXPANDED 06-13 178.91 176.80 109.16 132.97 119.05 106.32 0.00 0.00 0.00 0.00 0.00 0.00 823.21 111D TANF EXPANDED 14-20 110.01 125.19 98.05 81.38 99.28 97.55 0.00 0.00 0.00 0.00 0.00 0.00 611.46 19 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 ACUTE CAPITATION - MEMBER MONTHS 111E TANF EXPANDED 14-20 187.80 217.08 166.20 165.41 142.93 155.42 0.00 0.00 0.00 0.00 0.00 0.00 1,034.84 111F TANF EXPANDED 21-44 1,458.71 1,640.40 1,167.61 1,266.07 1,247.98 1,410.38 0.00 0.00 0.00 0.00 0.00 0.00 8,191.15 111G TANF EXPANDED 21-44 2,729.01 3,302.43 2,305.39 2,470.74 2,518.78 2,603.16 0.00 0.00 0.00 0.00 0.00 0.00 15,929.51 111H TANF EXPANDED 45-64 798.14 948.71 714.87 717.88 690.91 641.64 0.00 0.00 0.00 0.00 0.00 0.00 4,512.15 111J TANF EXPANDED 65+ M& 5.55 7.62 8.84 1.67 2.76 6.23 0.00 0.00 0.00 0.00 0.00 0.00 32.67 1126 TANF EXPANDED 21-44 32.19 30.70 32.40 30.90 31.00 33.77 0.00 0.00 0.00 0.00 0.00 0.00 190.96 1127 TANF EXPANDED 21-44 67.31 66.96 64.76 65.54 64.65 60.15 0.00 0.00 0.00 0.00 0.00 0.00 389.37 1128 TANF EXPANDED 45-64 117.67 123.08 122.25 117.00 113.22 118.77 0.00 0.00 0.00 0.00 0.00 0.00 711.99 1129 TANF EXPANDED 65+ M& 40.00 40.00 36.00 40.00 38.00 43.00 0.00 0.00 0.00 0.00 0.00 0.00 237.00 112F TANF EXPANDED 21-44 0.80 0.29 0.60 1.09 0.00 0.21 0.00 0.00 0.00 0.00 0.00 0.00 2.99 112G TANF EXPANDED 21-44 2.67 1.01 0.23 1.44 1.33 1.83 0.00 0.00 0.00 0.00 0.00 0.00 8.51 112H TANF EXPANDED 45-64 1.31 3.88 2.73 0.00 1.23 0.22 0.00 0.00 0.00 0.00 0.00 0.00 9.37 2400 SSI AGED EXPANDED WI 319.99 371.04 311.62 340.33 371.86 339.45 0.00 0.00 0.00 0.00 0.00 0.00 2,054.29 240Z SSI AGED EXPANDED WI 414.62 400.88 248.82 232.81 216.75 185.56 0.00 0.00 0.00 0.00 0.00 0.00 1,699.44 2410 SSI AGED EXPANDED NO 1,337.03 1,315.89 1,242.37 1,209.56 1,198.09 1,137.87 0.00 0.00 0.00 0.00 0.00 0.00 7,440.81 241Z SSI AGED EXPANDED NO 81.73 80.19 66.04 86.16 69.22 76.50 0.00 0.00 0.00 0.00 0.00 0.00 459.84 2420 SSI AGED EXPANDED WI 19,558.71 19,677.63 19,743.84 19,794.75 19,766.81 19,900.66 0.00 0.00 0.00 0.00 0.00 0.00 118,442.40 242Z SSI AGED EXPANDED WI 188.47 178.50 127.22 179.42 126.77 159.34 0.00 0.00 0.00 0.00 0.00 0.00 959.72 2520 SSI BLIND EXPANDED W 8.00 9.93 10.00 11.00 11.00 11.00 0.00 0.00 0.00 0.00 0.00 0.00 60.93 252Z SSI BLIND EXPANDED W 0.00 0.06 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.06 2600 SSI DISABLED EXPANDE 477.24 487.24 491.84 482.14 500.85 482.42 0.00 0.00 0.00 0.00 0.00 0.00 2,921.73 260Z SSI DISABLED EXPANDE 402.66 367.92 259.52 236.25 244.05 192.58 0.00 0.00 0.00 0.00 0.00 0.00 1,702.98 2610 SSI DISABLED EXPANDE 4,478.67 4,367.05 4,155.04 3,886.52 3,767.84 3,580.08 0.00 0.00 0.00 0.00 0.00 0.00 24,235.20 261Z SSI DISABLED EXPANDE 157.04 164.81 123.46 129.15 155.28 137.72 0.00 0.00 0.00 0.00 0.00 0.00 867.46 2620 SSI DISABLED EXPANDE 7,165.80 7,341.53 7,517.41 7,697.99 7,836.97 7,971.84 0.00 0.00 0.00 0.00 0.00 0.00 45,531.54 262Z SSI DISABLED EXPANDE 49.82 56.19 41.70 56.92 30.99 18.32 0.00 0.00 0.00 0.00 0.00 0.00 253.94 153,213.88 155,873.53 SUBTOTAL: 151,990.79 151,414.56 150,590.37 150,151.58 0.00 0.00 0.00 0.00 0.00 0.00 913,234.71 9911 SB PAYMENT FOR TANF 69.00 80.00 56.00 56.00 56.00 62.00 0.00 0.00 0.00 0.00 0.00 0.00 379.00 9922 SB PAYMENT FOR SSI E 2.00 2.00 1.00 0.00 2.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 8.00 9923 SB PAYMENT FOR SSI E 5.00 5.00 4.00 5.00 4.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 25.00 SUBTOTAL: 76.00 87.00 61.00 61.00 62.00 65.00 0.00 0.00 0.00 0.00 0.00 0.00 412.00 3306 AHC CARE MALE 21-44 6.00 5.00 5.00 4.00 5.00 5.00 0.00 0.00 0.00 0.00 0.00 0.00 30.00 3307 AHC CARE FEMALE 21-4 3.00 2.00 1.00 1.00 2.03 1.00 0.00 0.00 0.00 0.00 0.00 0.00 10.03 3308 AHC CARE M&F 45-64 W 13.00 14.00 13.00 13.00 13.00 12.00 0.00 0.00 0.00 0.00 0.00 0.00 78.00 3309 AHC CARE M&F 65+ W/ 9.00 10.32 10.00 11.00 11.00 10.00 0.00 0.00 0.00 0.00 0.00 0.00 61.32 330G AHC CARE FEMALE 21-4 0.00 0.00 0.00 0.00 1.96 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1.96 330J AHC CARE M&F 65+ W/ 0.00 2.67 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2.67 20 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 ACUTE CAPITATION - MEMBER MONTHS 3314 AHC CARE MALE 14-20 1,032.80 996.29 962.45 931.86 921.66 917.32 0.00 0.00 0.00 0.00 0.00 0.00 5,762.38 3315 AHC CARE FEMALE 14-2 1,283.43 1,230.38 1,213.17 1,173.16 1,195.93 1,165.75 0.00 0.00 0.00 0.00 0.00 0.00 7,261.82 3316 AHC CARE MALE 21-44 4,640.05 4,297.37 3,864.34 3,590.69 3,406.46 3,256.43 0.00 0.00 0.00 0.00 0.00 0.00 23,055.34 3317 AHC CARE FEMALE 21-4 4,793.33 4,482.29 4,044.64 3,798.41 3,628.77 3,444.88 0.00 0.00 0.00 0.00 0.00 0.00 24,192.32 3318 AHC CARE M&F 45-64 N 13,562.02 12,961.75 12,285.20 11,813.09 11,354.22 10,951.62 0.00 0.00 0.00 0.00 0.00 0.00 72,927.90 3319 AHC CARE M&F 65+ NO 0.00 0.00 0.00 0.00 0.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 1.00 331A AHC CARE M&F < 1 NO 0.00 0.00 0.00 0.33 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.33 331D AHC CARE MALE 14-20 5.16 9.02 6.08 9.08 4.26 10.93 0.00 0.00 0.00 0.00 0.00 0.00 44.53 331E AHC CARE FEMALE 14-2 9.26 13.45 13.94 10.49 6.96 5.57 0.00 0.00 0.00 0.00 0.00 0.00 59.67 331F AHC CARE MALE 21-44 28.68 21.45 11.03 20.53 12.93 8.49 0.00 0.00 0.00 0.00 0.00 0.00 103.11 331G AHC CARE FEMALE 21-4 20.38 35.89 15.22 13.90 10.25 14.03 0.00 0.00 0.00 0.00 0.00 0.00 109.67 331H AHC CARE M&F 45-64 N 57.08 54.35 35.13 57.76 19.60 24.60 0.00 0.00 0.00 0.00 0.00 0.00 248.52 331J AHC CARE M&F 65+ NO 0.00 0.00 0.00 4.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4.00 3326 AHC CARE MALE 21-44 6.00 6.00 6.00 6.00 7.00 7.00 0.00 0.00 0.00 0.00 0.00 0.00 38.00 3327 AHC CARE FEMALE 21-4 2.00 2.00 2.00 1.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 11.00 3328 AHC CARE M&F 45-64 W 12.00 12.00 16.00 17.00 18.00 17.00 0.00 0.00 0.00 0.00 0.00 0.00 92.00 3329 AHC CARE M&F 65+ W/ 2.00 -2.50 2.00 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 7.50 25,485.19 24,153.73 SUBTOTAL: 22,506.20 21,478.30 20,623.03 19,856.62 0.00 0.00 0.00 0.00 0.00 0.00 134,103.07 9933 SB PAYMENT FOR AHCCS 9.00 6.00 7.00 4.00 6.00 6.00 0.00 0.00 0.00 0.00 0.00 0.00 38.00 SUBTOTAL: 9.00 6.00 7.00 4.00 6.00 6.00 0.00 0.00 0.00 0.00 0.00 0.00 38.00 3606 AHC CARE/MI MALE 21- 6.00 8.00 5.00 7.00 7.00 7.00 0.00 0.00 0.00 0.00 0.00 0.00 40.00 3607 AHC CARE/MI FEMALE 2 2.00 2.00 1.00 1.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 10.00 3608 AHC CARE/MI M&F 45-6 8.87 8.54 7.00 10.90 11.99 12.35 0.00 0.00 0.00 0.00 0.00 0.00 59.65 360F AHC CARE/MI MALE 21- 0.00 3.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 3.00 360H AHC CARE/MI M&F 45-6 0.00 5.45 0.00 0.00 0.00 0.64 0.00 0.00 0.00 0.00 0.00 0.00 6.09 3614 AHC CARE/MI MALE 14- 7,069.28 6,898.12 6,736.61 6,642.90 6,532.41 6,426.60 0.00 0.00 0.00 0.00 0.00 0.00 40,305.92 3615 AHC CARE/MI FEMALE 1 6,395.51 6,285.14 6,082.72 5,990.76 5,913.46 5,853.52 0.00 0.00 0.00 0.00 0.00 0.00 36,521.11 3616 AHC CARE/MI MALE 21- 17,681.71 16,583.57 15,569.78 14,782.37 14,081.73 13,392.73 0.00 0.00 0.00 0.00 0.00 0.00 92,091.89 3617 AHC CARE/MI FEMALE 2 11,497.24 10,912.20 10,254.93 9,805.83 9,393.58 8,961.19 0.00 0.00 0.00 0.00 0.00 0.00 60,824.97 3618 AHC CARE/MI M&F 45-6 30,046.99 29,054.52 27,990.73 27,064.80 26,253.41 25,420.59 0.00 0.00 0.00 0.00 0.00 0.00 165,831.04 3619 AHC CARE/MI M&F 65+ 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 5.00 361D AHC CARE/MI MALE 14- 42.28 38.07 29.96 36.34 44.70 38.79 0.00 0.00 0.00 0.00 0.00 0.00 230.14 361E AHC CARE/MI FEMALE 1 39.77 63.65 35.73 39.12 25.31 48.42 0.00 0.00 0.00 0.00 0.00 0.00 252.00 361F AHC CARE/MI MALE 21- 74.26 66.42 61.46 77.13 40.56 80.07 0.00 0.00 0.00 0.00 0.00 0.00 399.90 361G AHC CARE/MI FEMALE 2 50.68 45.73 40.75 37.55 41.95 38.46 0.00 0.00 0.00 0.00 0.00 0.00 255.12 361H AHC CARE/MI M&F 45-6 103.01 98.79 79.40 100.77 63.27 87.35 0.00 0.00 0.00 0.00 0.00 0.00 532.59 361J AHC CARE/MI M&F 65+ 0.00 0.00 0.00 0.00 5.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 5.00 21 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 ACUTE CAPITATION - MEMBER MONTHS 3626 AHC CARE/MI MALE 21- 2.00 2.00 2.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 9.00 3628 AHC CARE/MI M&F 45-6 0.00 0.00 0.00 0.00 0.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 1.00 73,020.60 70,076.20 SUBTOTAL: 66,898.07 64,598.47 62,418.37 60,371.71 0.00 0.00 0.00 0.00 0.00 0.00 397,383.42 9936 SB PAYMENT FOR AHC C 26.00 27.00 20.00 15.00 22.00 21.00 0.00 0.00 0.00 0.00 0.00 0.00 131.00 SUBTOTAL: 26.00 27.00 20.00 15.00 22.00 21.00 0.00 0.00 0.00 0.00 0.00 0.00 131.00 4517 BC PATIENT FEMALE 21 17.00 15.93 14.93 15.25 15.42 18.75 0.00 0.00 0.00 0.00 0.00 0.00 97.28 4518 BC PATIENT FEMALE 45 177.54 185.10 198.58 210.34 207.73 216.39 0.00 0.00 0.00 0.00 0.00 0.00 1,195.68 4519 BC PATIENT FEMALE 65 0.00 0.00 0.00 0.00 0.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 1.00 451G BC PATIENT FEMALE 21 0.00 1.06 2.06 0.74 5.55 2.20 0.00 0.00 0.00 0.00 0.00 0.00 11.61 451H BC PATIENT FEMALE 45 9.38 8.82 16.66 10.57 8.20 14.49 0.00 0.00 0.00 0.00 0.00 0.00 68.12 4617 CC PATIENT FEMALE 21 10.00 10.00 10.99 12.93 13.73 16.37 0.00 0.00 0.00 0.00 0.00 0.00 74.02 4618 CC PATIENT FEMALE 45 16.00 16.93 17.66 18.73 17.73 18.80 0.00 0.00 0.00 0.00 0.00 0.00 105.85 461G CC PATIENT FEMALE 21 0.00 0.00 1.99 3.05 2.26 3.60 0.00 0.00 0.00 0.00 0.00 0.00 10.90 461H CC PATIENT FEMALE 45 0.00 1.06 1.33 1.25 1.26 2.19 0.00 0.00 0.00 0.00 0.00 0.00 7.09 SUBTOTAL: 229.92 238.90 264.20 272.86 271.88 293.79 0.00 0.00 0.00 0.00 0.00 0.00 1,571.55 8600 SSI BLIND FREEDOM/WO 1.00 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 6.00 8700 SSI DISABLED FREEDOM 1,199.56 1,201.86 1,198.06 1,208.57 1,193.68 1,179.65 0.00 0.00 0.00 0.00 0.00 0.00 7,181.38 870Z SSI DISABLED FREEDOM 44.79 19.98 34.85 34.53 20.21 25.21 0.00 0.00 0.00 0.00 0.00 0.00 179.57 8710 SSI DISABLED FREEDOM 204.27 205.54 192.30 189.16 189.70 187.97 0.00 0.00 0.00 0.00 0.00 0.00 1,168.94 871Z SSI DISABLED FREEDOM 42.57 18.35 33.02 58.60 47.05 29.63 0.00 0.00 0.00 0.00 0.00 0.00 229.22 8720 SSI DISABLED FREEDOM 162.27 161.41 163.00 150.06 148.26 158.80 0.00 0.00 0.00 0.00 0.00 0.00 943.80 872Z SSI DISABLED FREEDOM 10.69 9.57 4.00 1.96 6.72 1.12 0.00 0.00 0.00 0.00 0.00 0.00 34.06 SUBTOTAL: 1,665.15 1,617.71 1,626.23 1,643.88 1,606.62 1,583.38 0.00 0.00 0.00 0.00 0.00 0.00 9,742.97 TOTAL: 1,128,769.14 1,141,154.51 1,117,844.73 1,114,507.97 1,106,125.34 1,101,586.30 0.00 0.00 0.00 0.00 0.00 0.00 6,709,987.99 22 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 LONG TERM CARE CAPITATION - AMOUNTS 1000 TANF WITH MEDICARE 3,084.22 3,084.22 3,084.22 3,084.22 3,084.22 3,084.22 0.00 0.00 0.00 0.00 0.00 0.00 18,505.32 1010 TANF NON-MEDICARE 1,769,861.66 1,770,148.54 1,778,678.77 1,810,728.13 1,830,508.87 1,814,939.94 0.00 0.00 0.00 0.00 0.00 0.00 10,774,865.91 101Z TANF ALTCS NON-MEDIC 0.00 0.00 0.00 0.00 6,999.68 0.00 0.00 0.00 0.00 0.00 0.00 0.00 6,999.68 1020 TANF WITH QMB 6,168.44 6,168.44 6,168.44 6,168.44 6,168.44 6,168.44 0.00 0.00 0.00 0.00 0.00 0.00 37,010.64 2100 SSI AGED WITH MEDICA 30,902,003.43 31,049,195.48 31,067,327.90 29,061,381.86 29,247,115.25 29,032,221.04 0.00 0.00 0.00 0.00 0.00 0.00 180,359,244.96 210Z SSI AGED WITH MEDICA 649,356.96 731,494.62 577,011.84 597,387.73 572,489.16 478,182.79 0.00 0.00 0.00 0.00 0.00 0.00 3,605,923.10 2110 SSI AGED NON-MEDICAR 1,663,517.30 1,627,493.25 1,599,864.60 2,355,542.31 2,353,594.23 2,348,245.30 0.00 0.00 0.00 0.00 0.00 0.00 11,948,256.99 211Z SSI AGED NON-MEDICAR 30,085.47 10,327.64 9,798.11 29,092.86 13,352.88 11,895.76 0.00 0.00 0.00 0.00 0.00 0.00 104,552.72 2120 SSI AGED WITH QMB 17,549,222.44 17,665,857.36 17,793,672.01 16,712,978.69 16,732,292.89 16,636,365.51 0.00 0.00 0.00 0.00 0.00 0.00 103,090,388.90 212Z SSI AGED WITH QMB PP 12,965.87 11,781.47 21,566.19 22,270.18 18,723.76 11,865.22 0.00 0.00 0.00 0.00 0.00 0.00 99,172.69 2200 SSI DISABLED WITH ME 12,674,905.93 12,773,245.06 12,830,394.95 12,452,321.45 12,550,287.31 12,607,409.91 0.00 0.00 0.00 0.00 0.00 0.00 75,888,564.61 220Z SSI DISABLED WITH ME 95,331.46 92,184.90 105,975.22 75,496.78 92,285.09 59,868.85 0.00 0.00 0.00 0.00 0.00 0.00 521,142.30 2210 SSI DISABLED NON-MED 68,224,658.40 68,324,897.36 68,619,488.93 73,979,425.45 74,038,268.41 74,351,934.24 0.00 0.00 0.00 0.00 0.00 0.00 427,538,672.79 221Z SSI DISABLED NON-MED 96,149.26 95,156.37 48,488.18 85,652.38 81,919.53 78,809.75 0.00 0.00 0.00 0.00 0.00 0.00 486,175.47 2220 SSI DISABLED WITH QM 18,324,783.39 18,402,677.71 18,414,760.59 18,118,785.78 18,119,452.21 18,136,625.81 0.00 0.00 0.00 0.00 0.00 0.00 109,517,085.49 222Z SSI DISABLED WITH QM 421.48 5,806.73 3,205.16 930.99 2,478.61 1,118.49 0.00 0.00 0.00 0.00 0.00 0.00 13,961.46 2300 SSI BLIND WITH MEDIC 67,202.85 67,202.85 67,202.85 65,031.84 65,411.32 65,411.32 0.00 0.00 0.00 0.00 0.00 0.00 397,463.03 2310 SSI BLIND NON-MEDICA 359,879.83 372,864.04 299,002.60 469,230.15 396,740.03 395,373.92 0.00 0.00 0.00 0.00 0.00 0.00 2,293,090.57 2320 SSI BLIND WITH QMB 131,782.30 127,255.28 126,147.53 123,848.90 115,815.60 121,354.09 0.00 0.00 0.00 0.00 0.00 0.00 746,203.70 152,561,380.69 153,136,841.32 153,371,838.09 155,969,358.14 156,246,987.49 156,160,874.60 SUBTOTAL: 0.00 0.00 0.00 0.00 0.00 0.00 927,447,280.33 8700 SSI DISABLED FREEDOM 64,032.51 60,222.69 63,525.01 57,366.32 57,366.32 57,366.32 0.00 0.00 0.00 0.00 0.00 0.00 359,879.17 870Z SSI DISABLED FREEDOM 0.00 29.15 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 29.15 8710 SSI DISABLED FREEDOM 51,313.37 51,602.60 51,602.60 73,752.53 78,143.37 80,976.30 0.00 0.00 0.00 0.00 0.00 0.00 387,390.77 871Z SSI DISABLED FREEDOM 2,769.50 0.00 0.00 0.00 4,600.73 2,044.31 0.00 0.00 0.00 0.00 0.00 0.00 9,414.54 8720 SSI DISABLED FREEDOM 9,243.96 9,243.96 9,243.96 12,213.87 12,213.87 12,213.87 0.00 0.00 0.00 0.00 0.00 0.00 64,373.49 SUBTOTAL: 127,359.34 121,098.40 124,371.57 143,332.72 152,324.29 152,600.80 0.00 0.00 0.00 0.00 0.00 0.00 821,087.12 TOTAL: 152,688,740.03 153,257,939.72 153,496,209.66 156,112,690.86 156,399,311.78 156,313,475.40 0.00 0.00 0.00 0.00 0.00 0.00 928,268,367.45 23 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 LONG TERM CARE MEMBER MONTHS 1000 TANF WITH MEDICARE 1.00 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 6.00 1010 TANF NON-MEDICARE 576.63 576.74 579.17 582.48 580.59 583.51 0.00 0.00 0.00 0.00 0.00 0.00 3,479.12 101Z TANF ALTCS NON-MEDIC 0.00 0.00 0.00 0.00 7.86 0.00 0.00 0.00 0.00 0.00 0.00 0.00 7.86 1020 TANF WITH QMB 2.00 2.00 2.00 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 12.00 2100 SSI AGED WITH MEDICA 11,109.53 11,152.38 11,165.71 11,203.42 11,255.76 11,161.77 0.00 0.00 0.00 0.00 0.00 0.00 67,048.57 210Z SSI AGED WITH MEDICA 712.73 803.28 634.78 663.98 645.22 553.09 0.00 0.00 0.00 0.00 0.00 0.00 4,013.08 2110 SSI AGED NON-MEDICAR 600.88 589.25 578.57 580.62 576.09 575.10 0.00 0.00 0.00 0.00 0.00 0.00 3,500.51 211Z SSI AGED NON-MEDICAR 33.24 11.26 11.06 32.17 15.40 13.49 0.00 0.00 0.00 0.00 0.00 0.00 116.62 2120 SSI AGED WITH QMB 6,810.67 6,863.41 6,898.84 6,890.34 6,893.67 6,865.38 0.00 0.00 0.00 0.00 0.00 0.00 41,222.31 212Z SSI AGED WITH QMB PP 14.20 12.47 23.85 24.41 21.59 14.36 0.00 0.00 0.00 0.00 0.00 0.00 110.88 2200 SSI DISABLED WITH ME 4,346.80 4,380.57 4,391.80 4,420.69 4,456.91 4,476.45 0.00 0.00 0.00 0.00 0.00 0.00 26,473.22 220Z SSI DISABLED WITH ME 104.54 100.97 117.06 84.58 104.38 69.49 0.00 0.00 0.00 0.00 0.00 0.00 581.02 2210 SSI DISABLED NON-MED 22,790.91 22,793.11 22,847.84 22,982.09 23,003.72 23,122.24 0.00 0.00 0.00 0.00 0.00 0.00 137,539.91 221Z SSI DISABLED NON-MED 106.01 104.61 52.45 93.80 94.48 89.80 0.00 0.00 0.00 0.00 0.00 0.00 541.15 2220 SSI DISABLED WITH QM 6,235.35 6,267.85 6,278.34 6,326.34 6,325.12 6,328.23 0.00 0.00 0.00 0.00 0.00 0.00 37,761.23 222Z SSI DISABLED WITH QM 0.47 6.41 3.75 1.03 2.93 1.22 0.00 0.00 0.00 0.00 0.00 0.00 15.81 2300 SSI BLIND WITH MEDIC 22.00 22.00 22.00 23.00 24.00 24.00 0.00 0.00 0.00 0.00 0.00 0.00 137.00 2310 SSI BLIND NON-MEDICA 120.00 125.00 100.56 146.68 124.23 124.22 0.00 0.00 0.00 0.00 0.00 0.00 740.69 2320 SSI BLIND WITH QMB 48.93 47.45 48.00 48.00 46.00 47.00 0.00 0.00 0.00 0.00 0.00 0.00 285.38 53,635.89 53,859.76 SUBTOTAL: 53,756.78 54,106.63 54,180.95 54,052.35 0.00 0.00 0.00 0.00 0.00 0.00 323,592.36 8700 SSI DISABLED FREEDOM 21.03 19.97 21.00 20.00 20.00 20.00 0.00 0.00 0.00 0.00 0.00 0.00 122.00 870Z SSI DISABLED FREEDOM 0.00 0.03 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.03 8710 SSI DISABLED FREEDOM 17.93 18.00 18.00 17.99 18.96 19.58 0.00 0.00 0.00 0.00 0.00 0.00 110.46 871Z SSI DISABLED FREEDOM 3.06 0.00 0.00 0.00 5.16 2.41 0.00 0.00 0.00 0.00 0.00 0.00 10.63 8720 SSI DISABLED FREEDOM 3.00 3.00 3.00 4.00 4.00 4.00 0.00 0.00 0.00 0.00 0.00 0.00 21.00 SUBTOTAL: 45.02 41.00 42.00 41.99 48.12 45.99 0.00 0.00 0.00 0.00 0.00 0.00 264.12 TOTAL: 53,680.91 53,900.76 53,798.78 54,148.62 54,229.07 54,098.34 0.00 0.00 0.00 0.00 0.00 0.00 323,856.48 24 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 MENTAL HEALTH CAPITATION AMOUNTS - CHILDREN 1000 TANF WITH MEDICARE 38.41 115.23 115.23 115.23 76.82 76.82 0.00 0.00 0.00 0.00 0.00 0.00 537.74 1010 TANF NON-MEDICARE 10,828,047.87 10,870,337.28 10,926,108.60 10,870,030.00 10,779,267.17 10,736,555.25 0.00 0.00 0.00 0.00 0.00 0.00 65,010,346.17 2110 SSI AGED NON-MEDICAR 38.41 38.41 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 76.82 2120 SSI AGED WITH QMB 38.41 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 38.41 2200 SSI DISABLED WITH ME 192.05 0.00 38.41 38.41 38.41 38.41 0.00 0.00 0.00 0.00 0.00 0.00 345.69 2210 SSI DISABLED NON-MED 592,896.76 592,896.76 593,127.22 590,284.88 587,250.49 587,711.41 0.00 0.00 0.00 0.00 0.00 0.00 3,544,167.52 2220 SSI DISABLED WITH QM 537.74 691.38 691.38 691.38 691.38 652.97 0.00 0.00 0.00 0.00 0.00 0.00 3,956.23 2310 SSI BLIND NON-MEDICA 2,343.01 2,266.19 2,343.01 2,419.83 2,458.24 2,535.06 0.00 0.00 0.00 0.00 0.00 0.00 14,365.34 4300 SOBRA CHILD WITH MED 76.82 76.82 76.82 76.82 76.82 76.82 0.00 0.00 0.00 0.00 0.00 0.00 460.92 4310 SOBRA CHILD NON-MEDI 10,989,331.46 11,034,501.62 11,037,420.78 10,960,908.06 10,845,678.06 10,790,866.99 0.00 0.00 0.00 0.00 0.00 0.00 65,658,706.97 5010 SOBRA PREGNANT WOMAN 20,895.04 21,010.27 21,010.27 20,050.02 19,051.36 16,938.81 0.00 0.00 0.00 0.00 0.00 0.00 118,955.77 22,434,435.98 22,521,933.96 22,580,931.72 22,444,614.63 SUBTOTAL: 22,234,588.75 22,135,452.54 0.00 0.00 0.00 0.00 0.00 0.00 134,351,957.58 1110 TANF EXPANDED FOR FI 265,451.51 266,911.09 269,369.33 267,448.83 269,561.38 269,945.48 0.00 0.00 0.00 0.00 0.00 0.00 1,608,687.62 2610 SSI DISABLED EXPANDE 38.41 38.41 76.82 153.64 192.05 192.05 0.00 0.00 0.00 0.00 0.00 0.00 691.38 SUBTOTAL: 265,489.92 266,949.50 269,446.15 267,602.47 269,753.43 270,137.53 0.00 0.00 0.00 0.00 0.00 0.00 1,609,379.00 TOTAL: 22,699,925.90 22,788,883.46 22,850,377.87 22,712,217.10 22,504,342.18 22,405,590.07 0.00 0.00 0.00 0.00 0.00 0.00 135,961,336.58 25 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 MENTAL HEALTH CAPITATION MEMBER MONTHS - CHILDREN 1000 TANF WITH MEDICARE 1.00 3.00 3.00 3.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 14.00 1010 TANF NON-MEDICARE 281,907.00 283,008.00 284,460.00 283,000.00 280,637.00 279,525.00 0.00 0.00 0.00 0.00 0.00 0.00 1,692,537.00 2110 SSI AGED NON-MEDICAR 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2.00 2120 SSI AGED WITH QMB 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1.00 2200 SSI DISABLED WITH ME 5.00 0.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 9.00 2210 SSI DISABLED NON-MED 15,436.00 15,436.00 15,442.00 15,368.00 15,289.00 15,301.00 0.00 0.00 0.00 0.00 0.00 0.00 92,272.00 2220 SSI DISABLED WITH QM 14.00 18.00 18.00 18.00 18.00 17.00 0.00 0.00 0.00 0.00 0.00 0.00 103.00 2310 SSI BLIND NON-MEDICA 61.00 59.00 61.00 63.00 64.00 66.00 0.00 0.00 0.00 0.00 0.00 0.00 374.00 4300 SOBRA CHILD WITH MED 2.00 2.00 2.00 2.00 2.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 12.00 4310 SOBRA CHILD NON-MEDI 286,106.00 287,282.00 287,358.00 285,366.00 282,366.00 280,939.00 0.00 0.00 0.00 0.00 0.00 0.00 1,709,417.00 5010 SOBRA PREGNANT WOMAN 544.00 547.00 547.00 522.00 496.00 441.00 0.00 0.00 0.00 0.00 0.00 0.00 3,097.00 584,078.00 586,356.00 SUBTOTAL: 587,892.00 584,343.00 578,875.00 576,294.00 0.00 0.00 0.00 0.00 0.00 0.00 3,497,838.00 1110 TANF EXPANDED FOR FI 6,911.00 6,949.00 7,013.00 6,963.00 7,018.00 7,028.00 0.00 0.00 0.00 0.00 0.00 0.00 41,882.00 2610 SSI DISABLED EXPANDE 1.00 1.00 2.00 4.00 5.00 5.00 0.00 0.00 0.00 0.00 0.00 0.00 18.00 SUBTOTAL: 6,912.00 6,950.00 7,015.00 6,967.00 7,023.00 7,033.00 0.00 0.00 0.00 0.00 0.00 0.00 41,900.00 TOTAL: 590,990.00 593,306.00 594,907.00 591,310.00 585,898.00 583,327.00 0.00 0.00 0.00 0.00 0.00 0.00 3,539,738.00 26 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 MENTAL HEALTH CAPITATION AMOUNTS - ADULT 1000 TANF WITH MEDICARE 53,444.24 49,022.32 49,556.00 50,928.32 48,641.12 48,946.08 0.00 0.00 0.00 0.00 0.00 0.00 300,538.08 1010 TANF NON-MEDICARE 10,862,446.48 10,936,475.52 11,015,002.72 10,988,394.96 10,903,006.16 10,846,664.80 0.00 0.00 0.00 0.00 0.00 0.00 65,551,990.64 1020 TANF WITH QMB 1,524.80 1,448.56 1,753.52 1,448.56 1,372.32 1,372.32 0.00 0.00 0.00 0.00 0.00 0.00 8,920.08 2100 SSI AGED WITH MEDICA 312,202.80 306,256.08 307,704.64 309,229.44 312,431.52 312,355.28 0.00 0.00 0.00 0.00 0.00 0.00 1,860,179.76 2110 SSI AGED NON-MEDICAR 397,744.08 390,730.00 391,416.16 387,604.16 385,469.44 383,029.76 0.00 0.00 0.00 0.00 0.00 0.00 2,335,993.60 2120 SSI AGED WITH QMB 1,535,473.60 1,546,070.96 1,550,721.60 1,552,627.60 1,549,120.56 1,544,393.68 0.00 0.00 0.00 0.00 0.00 0.00 9,278,408.00 2200 SSI DISABLED WITH ME 305,341.20 305,569.92 307,628.40 311,974.08 313,803.84 317,997.04 0.00 0.00 0.00 0.00 0.00 0.00 1,862,314.48 2210 SSI DISABLED NON-MED 3,423,557.20 3,437,585.36 3,468,157.60 3,504,981.52 3,528,692.16 3,545,617.44 0.00 0.00 0.00 0.00 0.00 0.00 20,908,591.28 2220 SSI DISABLED WITH QM 2,106,206.24 2,125,190.00 2,138,608.24 2,147,833.28 2,161,251.52 2,166,435.84 0.00 0.00 0.00 0.00 0.00 0.00 12,845,525.12 2300 SSI BLIND WITH MEDIC 2,058.48 1,982.24 2,058.48 2,134.72 2,134.72 2,134.72 0.00 0.00 0.00 0.00 0.00 0.00 12,503.36 2310 SSI BLIND NON-MEDICA 29,581.12 29,886.08 30,419.76 30,343.52 29,962.32 30,267.28 0.00 0.00 0.00 0.00 0.00 0.00 180,460.08 2320 SSI BLIND WITH QMB 18,755.04 18,526.32 18,678.80 19,060.00 18,907.52 18,983.76 0.00 0.00 0.00 0.00 0.00 0.00 112,911.44 4300 SOBRA CHILD WITH MED 0.00 0.00 0.00 0.00 76.24 76.24 0.00 0.00 0.00 0.00 0.00 0.00 152.48 4310 SOBRA CHILD NON-MEDI 1,444,214.32 1,435,522.96 1,422,409.68 1,372,015.04 1,332,751.44 1,300,425.68 0.00 0.00 0.00 0.00 0.00 0.00 8,307,339.12 5000 SOBRA PREGNANT WOMAN 4,421.92 4,574.40 4,955.60 4,498.16 4,574.40 4,803.12 0.00 0.00 0.00 0.00 0.00 0.00 27,827.60 5010 SOBRA PREGNANT WOMAN 1,091,604.32 1,115,238.72 1,133,078.88 1,113,637.68 1,074,907.76 1,030,459.84 0.00 0.00 0.00 0.00 0.00 0.00 6,558,927.20 5020 SOBRA PREGNANT WOMAN 228.72 76.24 152.48 0.00 0.00 76.24 0.00 0.00 0.00 0.00 0.00 0.00 533.68 21,588,804.56 21,704,155.68 21,842,302.56 21,796,711.04 SUBTOTAL: 21,667,103.04 21,554,039.12 0.00 0.00 0.00 0.00 0.00 0.00 130,153,116.00 1100 TANF EXPANDED FPR FI 398,049.04 402,699.68 404,758.16 402,775.92 404,072.00 403,767.04 0.00 0.00 0.00 0.00 0.00 0.00 2,416,121.84 1110 TANF EXPANDED FOR FI 7,910,052.48 7,940,014.80 7,928,731.28 7,833,812.48 7,744,840.40 7,682,781.04 0.00 0.00 0.00 0.00 0.00 0.00 47,040,232.48 1120 TANF EXPANDED FOR FI 20,661.04 20,508.56 20,127.36 20,203.60 19,746.16 20,356.08 0.00 0.00 0.00 0.00 0.00 0.00 121,602.80 2400 SSI AGED EXPANDED WI 19,822.40 22,795.76 20,966.00 22,262.08 25,464.16 23,329.44 0.00 0.00 0.00 0.00 0.00 0.00 134,639.84 2410 SSI AGED EXPANDED NO 102,237.84 100,331.84 96,062.40 92,555.36 92,174.16 86,761.12 0.00 0.00 0.00 0.00 0.00 0.00 570,122.72 2420 SSI AGED EXPANDED WI 1,568,714.24 1,572,602.48 1,583,809.76 1,587,545.52 1,585,868.24 1,593,111.04 0.00 0.00 0.00 0.00 0.00 0.00 9,491,651.28 2520 SSI BLIND EXPANDED W 686.16 762.40 838.64 914.88 914.88 914.88 0.00 0.00 0.00 0.00 0.00 0.00 5,031.84 2600 SSI DISABLED EXPANDE 32,249.52 33,164.40 34,536.72 33,469.36 34,231.76 34,841.68 0.00 0.00 0.00 0.00 0.00 0.00 202,493.44 2610 SSI DISABLED EXPANDE 357,565.60 347,501.92 331,796.48 307,552.16 297,793.44 284,603.92 0.00 0.00 0.00 0.00 0.00 0.00 1,926,813.52 2620 SSI DISABLED EXPANDE 569,055.36 581,482.48 596,959.20 611,444.80 622,652.08 634,011.84 0.00 0.00 0.00 0.00 0.00 0.00 3,615,605.76 SUBTOTAL: 10,979,093.68 11,021,864.32 11,018,586.00 10,912,536.16 10,827,757.28 10,764,478.08 0.00 0.00 0.00 0.00 0.00 0.00 65,524,315.52 3300 AHC CARE EXPANDED FO 2,515.92 2,515.92 2,287.20 2,287.20 2,363.44 2,287.20 0.00 0.00 0.00 0.00 0.00 0.00 14,256.88 3310 AHC CARE EXPANDED FO 2,011,668.64 1,903,331.60 1,774,562.24 1,690,622.00 1,625,055.60 1,561,776.40 0.00 0.00 0.00 0.00 0.00 0.00 10,567,016.48 3320 AHC CARE EXPANDED FO 1,753.52 1,829.76 2,134.72 2,134.72 2,363.44 2,287.20 0.00 0.00 0.00 0.00 0.00 0.00 12,503.36 SUBTOTAL: 2,015,938.08 1,907,677.28 1,778,984.16 1,695,043.92 1,629,782.48 1,566,350.80 0.00 0.00 0.00 0.00 0.00 0.00 10,593,776.72 3600 AHC CARE EXPANDED FO 1,524.80 1,601.04 1,143.60 1,448.56 1,677.28 1,677.28 0.00 0.00 0.00 0.00 0.00 0.00 9,072.56 3610 AHC CARE EXPANDED FO 6,362,075.52 6,102,859.52 5,841,432.56 5,632,916.16 5,446,890.56 5,253,393.44 0.00 0.00 0.00 0.00 0.00 0.00 34,639,567.76 3620 AHC CARE EXPANDED FO 152.48 152.48 152.48 76.24 76.24 152.48 0.00 0.00 0.00 0.00 0.00 0.00 762.40 27 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 MENTAL HEALTH CAPITATION AMOUNTS - ADULT 6,363,752.80 6,104,613.04 SUBTOTAL: 5,842,728.64 5,634,440.96 5,448,644.08 5,255,223.20 0.00 0.00 0.00 0.00 0.00 0.00 34,649,402.72 4510 BC PATIENT FOR FINAN 14,561.84 15,095.52 15,781.68 16,849.04 16,239.12 17,077.76 0.00 0.00 0.00 0.00 0.00 0.00 95,604.96 4610 CC PATIENT FOR FINAN 2,058.48 2,058.48 2,134.72 2,363.44 2,287.20 2,515.92 0.00 0.00 0.00 0.00 0.00 0.00 13,418.24 SUBTOTAL: 16,620.32 17,154.00 17,916.40 19,212.48 18,526.32 19,593.68 0.00 0.00 0.00 0.00 0.00 0.00 109,023.20 8600 SSI BLIND FREEDOM/WO 76.24 76.24 76.24 76.24 76.24 76.24 0.00 0.00 0.00 0.00 0.00 0.00 457.44 8700 SSI DISABLED FREEDOM 91,488.00 91,030.56 90,954.32 92,021.68 90,344.40 90,039.44 0.00 0.00 0.00 0.00 0.00 0.00 545,878.40 8710 SSI DISABLED FREEDOM 14,943.04 15,019.28 14,333.12 13,951.92 13,875.68 13,875.68 0.00 0.00 0.00 0.00 0.00 0.00 85,998.72 8720 SSI DISABLED FREEDOM 12,274.64 12,427.12 12,579.60 11,740.96 11,512.24 12,045.92 0.00 0.00 0.00 0.00 0.00 0.00 72,580.48 SUBTOTAL: 118,781.92 118,553.20 117,943.28 117,790.80 115,808.56 116,037.28 0.00 0.00 0.00 0.00 0.00 0.00 704,915.04 TOTAL: 41,082,991.36 40,874,017.52 40,618,461.04 40,175,735.36 39,707,621.76 39,275,722.16 0.00 0.00 0.00 0.00 0.00 0.00 241,734,549.20 28 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT 1000 TANF WITH MEDICARE 701.00 643.00 650.00 668.00 638.00 642.00 0.00 0.00 0.00 0.00 0.00 0.00 3,942.00 1010 TANF NON-MEDICARE 142,477.00 143,448.00 144,478.00 144,129.00 143,009.00 142,270.00 0.00 0.00 0.00 0.00 0.00 0.00 859,811.00 1020 TANF WITH QMB 20.00 19.00 23.00 19.00 18.00 18.00 0.00 0.00 0.00 0.00 0.00 0.00 117.00 2100 SSI AGED WITH MEDICA 4,095.00 4,017.00 4,036.00 4,056.00 4,098.00 4,097.00 0.00 0.00 0.00 0.00 0.00 0.00 24,399.00 2110 SSI AGED NON-MEDICAR 5,217.00 5,125.00 5,134.00 5,084.00 5,056.00 5,024.00 0.00 0.00 0.00 0.00 0.00 0.00 30,640.00 2120 SSI AGED WITH QMB 20,140.00 20,279.00 20,340.00 20,365.00 20,319.00 20,257.00 0.00 0.00 0.00 0.00 0.00 0.00 121,700.00 2200 SSI DISABLED WITH ME 4,005.00 4,008.00 4,035.00 4,092.00 4,116.00 4,171.00 0.00 0.00 0.00 0.00 0.00 0.00 24,427.00 2210 SSI DISABLED NON-MED 44,905.00 45,089.00 45,490.00 45,973.00 46,284.00 46,506.00 0.00 0.00 0.00 0.00 0.00 0.00 274,247.00 2220 SSI DISABLED WITH QM 27,626.00 27,875.00 28,051.00 28,172.00 28,348.00 28,416.00 0.00 0.00 0.00 0.00 0.00 0.00 168,488.00 2300 SSI BLIND WITH MEDIC 27.00 26.00 27.00 28.00 28.00 28.00 0.00 0.00 0.00 0.00 0.00 0.00 164.00 2310 SSI BLIND NON-MEDICA 388.00 392.00 399.00 398.00 393.00 397.00 0.00 0.00 0.00 0.00 0.00 0.00 2,367.00 2320 SSI BLIND WITH QMB 246.00 243.00 245.00 250.00 248.00 249.00 0.00 0.00 0.00 0.00 0.00 0.00 1,481.00 4300 SOBRA CHILD WITH MED 0.00 0.00 0.00 0.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 2.00 4310 SOBRA CHILD NON-MEDI 18,943.00 18,829.00 18,657.00 17,996.00 17,481.00 17,057.00 0.00 0.00 0.00 0.00 0.00 0.00 108,963.00 5000 SOBRA PREGNANT WOMAN 58.00 60.00 65.00 59.00 60.00 63.00 0.00 0.00 0.00 0.00 0.00 0.00 365.00 5010 SOBRA PREGNANT WOMAN 14,318.00 14,628.00 14,862.00 14,607.00 14,099.00 13,516.00 0.00 0.00 0.00 0.00 0.00 0.00 86,030.00 5020 SOBRA PREGNANT WOMAN 3.00 1.00 2.00 0.00 0.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 7.00 283,169.00 284,682.00 SUBTOTAL: 286,494.00 285,896.00 284,196.00 282,713.00 0.00 0.00 0.00 0.00 0.00 0.00 1,707,150.00 1100 TANF EXPANDED FPR FI 5,221.00 5,282.00 5,309.00 5,283.00 5,300.00 5,296.00 0.00 0.00 0.00 0.00 0.00 0.00 31,691.00 1110 TANF EXPANDED FOR FI 103,752.00 104,145.00 103,997.00 102,752.00 101,585.00 100,771.00 0.00 0.00 0.00 0.00 0.00 0.00 617,002.00 1120 TANF EXPANDED FOR FI 271.00 269.00 264.00 265.00 259.00 267.00 0.00 0.00 0.00 0.00 0.00 0.00 1,595.00 2400 SSI AGED EXPANDED WI 260.00 299.00 275.00 292.00 334.00 306.00 0.00 0.00 0.00 0.00 0.00 0.00 1,766.00 2410 SSI AGED EXPANDED NO 1,341.00 1,316.00 1,260.00 1,214.00 1,209.00 1,138.00 0.00 0.00 0.00 0.00 0.00 0.00 7,478.00 2420 SSI AGED EXPANDED WI 20,576.00 20,627.00 20,774.00 20,823.00 20,801.00 20,896.00 0.00 0.00 0.00 0.00 0.00 0.00 124,497.00 2520 SSI BLIND EXPANDED W 9.00 10.00 11.00 12.00 12.00 12.00 0.00 0.00 0.00 0.00 0.00 0.00 66.00 2600 SSI DISABLED EXPANDE 423.00 435.00 453.00 439.00 449.00 457.00 0.00 0.00 0.00 0.00 0.00 0.00 2,656.00 2610 SSI DISABLED EXPANDE 4,690.00 4,558.00 4,352.00 4,034.00 3,906.00 3,733.00 0.00 0.00 0.00 0.00 0.00 0.00 25,273.00 2620 SSI DISABLED EXPANDE 7,464.00 7,627.00 7,830.00 8,020.00 8,167.00 8,316.00 0.00 0.00 0.00 0.00 0.00 0.00 47,424.00 SUBTOTAL: 144,007.00 144,568.00 144,525.00 143,134.00 142,022.00 141,192.00 0.00 0.00 0.00 0.00 0.00 0.00 859,448.00 3300 AHC CARE EXPANDED FO 33.00 33.00 30.00 30.00 31.00 30.00 0.00 0.00 0.00 0.00 0.00 0.00 187.00 3310 AHC CARE EXPANDED FO 26,386.00 24,965.00 23,276.00 22,175.00 21,315.00 20,485.00 0.00 0.00 0.00 0.00 0.00 0.00 138,602.00 3320 AHC CARE EXPANDED FO 23.00 24.00 28.00 28.00 31.00 30.00 0.00 0.00 0.00 0.00 0.00 0.00 164.00 SUBTOTAL: 26,442.00 25,022.00 23,334.00 22,233.00 21,377.00 20,545.00 0.00 0.00 0.00 0.00 0.00 0.00 138,953.00 3600 AHC CARE EXPANDED FO 20.00 21.00 15.00 19.00 22.00 22.00 0.00 0.00 0.00 0.00 0.00 0.00 119.00 3610 AHC CARE EXPANDED FO 83,448.00 80,048.00 76,619.00 73,884.00 71,444.00 68,906.00 0.00 0.00 0.00 0.00 0.00 0.00 454,349.00 3620 AHC CARE EXPANDED FO 2.00 2.00 2.00 1.00 1.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 10.00 29 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 MENTAL HEALTH CAPITATION MEMBER MONTHS - ADULT 83,470.00 80,071.00 SUBTOTAL: 76,636.00 73,904.00 71,467.00 68,930.00 0.00 0.00 0.00 0.00 0.00 0.00 454,478.00 4510 BC PATIENT FOR FINAN 191.00 198.00 207.00 221.00 213.00 224.00 0.00 0.00 0.00 0.00 0.00 0.00 1,254.00 4610 CC PATIENT FOR FINAN 27.00 27.00 28.00 31.00 30.00 33.00 0.00 0.00 0.00 0.00 0.00 0.00 176.00 SUBTOTAL: 218.00 225.00 235.00 252.00 243.00 257.00 0.00 0.00 0.00 0.00 0.00 0.00 1,430.00 8600 SSI BLIND FREEDOM/WO 1.00 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 6.00 8700 SSI DISABLED FREEDOM 1,200.00 1,194.00 1,193.00 1,207.00 1,185.00 1,181.00 0.00 0.00 0.00 0.00 0.00 0.00 7,160.00 8710 SSI DISABLED FREEDOM 196.00 197.00 188.00 183.00 182.00 182.00 0.00 0.00 0.00 0.00 0.00 0.00 1,128.00 8720 SSI DISABLED FREEDOM 161.00 163.00 165.00 154.00 151.00 158.00 0.00 0.00 0.00 0.00 0.00 0.00 952.00 SUBTOTAL: 1,558.00 1,555.00 1,547.00 1,545.00 1,519.00 1,522.00 0.00 0.00 0.00 0.00 0.00 0.00 9,246.00 TOTAL: 538,864.00 536,123.00 532,771.00 526,964.00 520,824.00 515,159.00 0.00 0.00 0.00 0.00 0.00 0.00 3,170,705.00 30 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 MENTAL HEALTH CAPITATION AMOUNTS - GENERAL 1000 TANF WITH MEDICARE 30,346.29 27,835.47 28,138.50 28,917.72 27,619.02 27,792.18 0.00 0.00 0.00 0.00 0.00 0.00 170,649.18 1010 TANF NON-MEDICARE 6,167,829.33 6,209,863.92 6,254,452.62 6,239,344.41 6,190,859.61 6,158,868.30 0.00 0.00 0.00 0.00 0.00 0.00 37,221,218.19 1020 TANF WITH QMB 865.80 822.51 995.67 822.51 779.22 779.22 0.00 0.00 0.00 0.00 0.00 0.00 5,064.93 2100 SSI AGED WITH MEDICA 177,272.55 173,895.93 174,718.44 175,584.24 177,402.42 177,359.13 0.00 0.00 0.00 0.00 0.00 0.00 1,056,232.71 2110 SSI AGED NON-MEDICAR 225,843.93 221,861.25 222,250.86 220,086.36 218,874.24 217,488.96 0.00 0.00 0.00 0.00 0.00 0.00 1,326,405.60 2120 SSI AGED WITH QMB 871,860.60 877,877.91 880,518.60 881,600.85 879,609.51 876,925.53 0.00 0.00 0.00 0.00 0.00 0.00 5,268,393.00 2200 SSI DISABLED WITH ME 173,376.45 173,506.32 174,675.15 177,142.68 178,181.64 180,562.59 0.00 0.00 0.00 0.00 0.00 0.00 1,057,444.83 2210 SSI DISABLED NON-MED 1,943,937.45 1,951,902.81 1,969,262.10 1,990,171.17 2,003,634.36 2,013,244.74 0.00 0.00 0.00 0.00 0.00 0.00 11,872,152.63 2220 SSI DISABLED WITH QM 1,195,929.54 1,206,708.75 1,214,327.79 1,219,565.88 1,227,184.92 1,230,128.64 0.00 0.00 0.00 0.00 0.00 0.00 7,293,845.52 2300 SSI BLIND WITH MEDIC 1,168.83 1,125.54 1,168.83 1,212.12 1,212.12 1,212.12 0.00 0.00 0.00 0.00 0.00 0.00 7,099.56 2310 SSI BLIND NON-MEDICA 16,796.52 16,969.68 17,272.71 17,229.42 17,012.97 17,186.13 0.00 0.00 0.00 0.00 0.00 0.00 102,467.43 2320 SSI BLIND WITH QMB 10,649.34 10,519.47 10,606.05 10,822.50 10,735.92 10,779.21 0.00 0.00 0.00 0.00 0.00 0.00 64,112.49 4300 SOBRA CHILD WITH MED 0.00 0.00 0.00 0.00 43.29 43.29 0.00 0.00 0.00 0.00 0.00 0.00 86.58 4310 SOBRA CHILD NON-MEDI 820,042.47 815,107.41 807,661.53 779,046.84 756,752.49 738,397.53 0.00 0.00 0.00 0.00 0.00 0.00 4,717,008.27 5000 SOBRA PREGNANT WOMAN 2,510.82 2,597.40 2,813.85 2,554.11 2,597.40 2,727.27 0.00 0.00 0.00 0.00 0.00 0.00 15,800.85 5010 SOBRA PREGNANT WOMAN 619,826.22 633,246.12 643,375.98 632,337.03 610,345.71 585,107.64 0.00 0.00 0.00 0.00 0.00 0.00 3,724,238.70 5020 SOBRA PREGNANT WOMAN 129.87 43.29 86.58 0.00 0.00 43.29 0.00 0.00 0.00 0.00 0.00 0.00 303.03 12,258,386.01 12,323,883.78 12,402,325.26 12,376,437.84 SUBTOTAL: 12,302,844.84 12,238,645.77 0.00 0.00 0.00 0.00 0.00 0.00 73,902,523.50 1100 TANF EXPANDED FPR FI 226,017.09 228,657.78 229,826.61 228,701.07 229,437.00 229,263.84 0.00 0.00 0.00 0.00 0.00 0.00 1,371,903.39 1110 TANF EXPANDED FOR FI 4,491,424.08 4,508,437.05 4,502,030.13 4,448,134.08 4,397,614.65 4,362,376.59 0.00 0.00 0.00 0.00 0.00 0.00 26,710,016.58 1120 TANF EXPANDED FOR FI 11,731.59 11,645.01 11,428.56 11,471.85 11,212.11 11,558.43 0.00 0.00 0.00 0.00 0.00 0.00 69,047.55 2400 SSI AGED EXPANDED WI 11,255.40 12,943.71 11,904.75 12,640.68 14,458.86 13,246.74 0.00 0.00 0.00 0.00 0.00 0.00 76,450.14 2410 SSI AGED EXPANDED NO 58,051.89 56,969.64 54,545.40 52,554.06 52,337.61 49,264.02 0.00 0.00 0.00 0.00 0.00 0.00 323,722.62 2420 SSI AGED EXPANDED WI 890,735.04 892,942.83 899,306.46 901,427.67 900,475.29 904,587.84 0.00 0.00 0.00 0.00 0.00 0.00 5,389,475.13 2520 SSI BLIND EXPANDED W 389.61 432.90 476.19 519.48 519.48 519.48 0.00 0.00 0.00 0.00 0.00 0.00 2,857.14 2600 SSI DISABLED EXPANDE 18,311.67 18,831.15 19,610.37 19,004.31 19,437.21 19,783.53 0.00 0.00 0.00 0.00 0.00 0.00 114,978.24 2610 SSI DISABLED EXPANDE 203,030.10 197,315.82 188,398.08 174,631.86 169,090.74 161,601.57 0.00 0.00 0.00 0.00 0.00 0.00 1,094,068.17 2620 SSI DISABLED EXPANDE 323,116.56 330,172.83 338,960.70 347,185.80 353,549.43 359,999.64 0.00 0.00 0.00 0.00 0.00 0.00 2,052,984.96 SUBTOTAL: 6,234,063.03 6,258,348.72 6,256,487.25 6,196,270.86 6,148,132.38 6,112,201.68 0.00 0.00 0.00 0.00 0.00 0.00 37,205,503.92 3300 AHC CARE EXPANDED FO 1,428.57 1,428.57 1,298.70 1,298.70 1,341.99 1,298.70 0.00 0.00 0.00 0.00 0.00 0.00 8,095.23 3310 AHC CARE EXPANDED FO 1,142,249.94 1,080,734.85 1,007,618.04 959,955.75 922,726.35 886,795.65 0.00 0.00 0.00 0.00 0.00 0.00 6,000,080.58 3320 AHC CARE EXPANDED FO 995.67 1,038.96 1,212.12 1,212.12 1,341.99 1,298.70 0.00 0.00 0.00 0.00 0.00 0.00 7,099.56 SUBTOTAL: 1,144,674.18 1,083,202.38 1,010,128.86 962,466.57 925,410.33 889,393.05 0.00 0.00 0.00 0.00 0.00 0.00 6,015,275.37 3600 AHC CARE EXPANDED FO 865.80 909.09 649.35 822.51 952.38 952.38 0.00 0.00 0.00 0.00 0.00 0.00 5,151.51 3610 AHC CARE EXPANDED FO 3,612,463.92 3,465,277.92 3,316,836.51 3,198,438.36 3,092,810.76 2,982,940.74 0.00 0.00 0.00 0.00 0.00 0.00 19,668,768.21 3620 AHC CARE EXPANDED FO 86.58 86.58 86.58 43.29 43.29 86.58 0.00 0.00 0.00 0.00 0.00 0.00 432.90 31 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 MENTAL HEALTH CAPITATION AMOUNTS - GENERAL 3,613,416.30 3,466,273.59 SUBTOTAL: 3,317,572.44 3,199,304.16 3,093,806.43 2,983,979.70 0.00 0.00 0.00 0.00 0.00 0.00 19,674,352.62 4510 BC PATIENT FOR FINAN 8,268.39 8,571.42 8,961.03 9,567.09 9,220.77 9,696.96 0.00 0.00 0.00 0.00 0.00 0.00 54,285.66 4610 CC PATIENT FOR FINAN 1,168.83 1,168.83 1,212.12 1,341.99 1,298.70 1,428.57 0.00 0.00 0.00 0.00 0.00 0.00 7,619.04 SUBTOTAL: 9,437.22 9,740.25 10,173.15 10,909.08 10,519.47 11,125.53 0.00 0.00 0.00 0.00 0.00 0.00 61,904.70 8600 SSI BLIND FREEDOM/WO 43.29 43.29 43.29 43.29 43.29 43.29 0.00 0.00 0.00 0.00 0.00 0.00 259.74 8700 SSI DISABLED FREEDOM 51,948.00 51,688.26 51,644.97 52,251.03 51,298.65 51,125.49 0.00 0.00 0.00 0.00 0.00 0.00 309,956.40 8710 SSI DISABLED FREEDOM 8,484.84 8,528.13 8,138.52 7,922.07 7,878.78 7,878.78 0.00 0.00 0.00 0.00 0.00 0.00 48,831.12 8720 SSI DISABLED FREEDOM 6,969.69 7,056.27 7,142.85 6,666.66 6,536.79 6,839.82 0.00 0.00 0.00 0.00 0.00 0.00 41,212.08 SUBTOTAL: 67,445.82 67,315.95 66,969.63 66,883.05 65,757.51 65,887.38 0.00 0.00 0.00 0.00 0.00 0.00 400,259.34 TOTAL: 23,327,422.56 23,208,764.67 23,063,656.59 22,812,271.56 22,546,470.96 22,301,233.11 0.00 0.00 0.00 0.00 0.00 0.00 137,259,819.45 32 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL 1000 TANF WITH MEDICARE 701.00 643.00 650.00 668.00 638.00 642.00 0.00 0.00 0.00 0.00 0.00 0.00 3,942.00 1010 TANF NON-MEDICARE 142,477.00 143,448.00 144,478.00 144,129.00 143,009.00 142,270.00 0.00 0.00 0.00 0.00 0.00 0.00 859,811.00 1020 TANF WITH QMB 20.00 19.00 23.00 19.00 18.00 18.00 0.00 0.00 0.00 0.00 0.00 0.00 117.00 2100 SSI AGED WITH MEDICA 4,095.00 4,017.00 4,036.00 4,056.00 4,098.00 4,097.00 0.00 0.00 0.00 0.00 0.00 0.00 24,399.00 2110 SSI AGED NON-MEDICAR 5,217.00 5,125.00 5,134.00 5,084.00 5,056.00 5,024.00 0.00 0.00 0.00 0.00 0.00 0.00 30,640.00 2120 SSI AGED WITH QMB 20,140.00 20,279.00 20,340.00 20,365.00 20,319.00 20,257.00 0.00 0.00 0.00 0.00 0.00 0.00 121,700.00 2200 SSI DISABLED WITH ME 4,005.00 4,008.00 4,035.00 4,092.00 4,116.00 4,171.00 0.00 0.00 0.00 0.00 0.00 0.00 24,427.00 2210 SSI DISABLED NON-MED 44,905.00 45,089.00 45,490.00 45,973.00 46,284.00 46,506.00 0.00 0.00 0.00 0.00 0.00 0.00 274,247.00 2220 SSI DISABLED WITH QM 27,626.00 27,875.00 28,051.00 28,172.00 28,348.00 28,416.00 0.00 0.00 0.00 0.00 0.00 0.00 168,488.00 2300 SSI BLIND WITH MEDIC 27.00 26.00 27.00 28.00 28.00 28.00 0.00 0.00 0.00 0.00 0.00 0.00 164.00 2310 SSI BLIND NON-MEDICA 388.00 392.00 399.00 398.00 393.00 397.00 0.00 0.00 0.00 0.00 0.00 0.00 2,367.00 2320 SSI BLIND WITH QMB 246.00 243.00 245.00 250.00 248.00 249.00 0.00 0.00 0.00 0.00 0.00 0.00 1,481.00 4300 SOBRA CHILD WITH MED 0.00 0.00 0.00 0.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 2.00 4310 SOBRA CHILD NON-MEDI 18,943.00 18,829.00 18,657.00 17,996.00 17,481.00 17,057.00 0.00 0.00 0.00 0.00 0.00 0.00 108,963.00 5000 SOBRA PREGNANT WOMAN 58.00 60.00 65.00 59.00 60.00 63.00 0.00 0.00 0.00 0.00 0.00 0.00 365.00 5010 SOBRA PREGNANT WOMAN 14,318.00 14,628.00 14,862.00 14,607.00 14,099.00 13,516.00 0.00 0.00 0.00 0.00 0.00 0.00 86,030.00 5020 SOBRA PREGNANT WOMAN 3.00 1.00 2.00 0.00 0.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 7.00 283,169.00 284,682.00 SUBTOTAL: 286,494.00 285,896.00 284,196.00 282,713.00 0.00 0.00 0.00 0.00 0.00 0.00 1,707,150.00 1100 TANF EXPANDED FPR FI 5,221.00 5,282.00 5,309.00 5,283.00 5,300.00 5,296.00 0.00 0.00 0.00 0.00 0.00 0.00 31,691.00 1110 TANF EXPANDED FOR FI 103,752.00 104,145.00 103,997.00 102,752.00 101,585.00 100,771.00 0.00 0.00 0.00 0.00 0.00 0.00 617,002.00 1120 TANF EXPANDED FOR FI 271.00 269.00 264.00 265.00 259.00 267.00 0.00 0.00 0.00 0.00 0.00 0.00 1,595.00 2400 SSI AGED EXPANDED WI 260.00 299.00 275.00 292.00 334.00 306.00 0.00 0.00 0.00 0.00 0.00 0.00 1,766.00 2410 SSI AGED EXPANDED NO 1,341.00 1,316.00 1,260.00 1,214.00 1,209.00 1,138.00 0.00 0.00 0.00 0.00 0.00 0.00 7,478.00 2420 SSI AGED EXPANDED WI 20,576.00 20,627.00 20,774.00 20,823.00 20,801.00 20,896.00 0.00 0.00 0.00 0.00 0.00 0.00 124,497.00 2520 SSI BLIND EXPANDED W 9.00 10.00 11.00 12.00 12.00 12.00 0.00 0.00 0.00 0.00 0.00 0.00 66.00 2600 SSI DISABLED EXPANDE 423.00 435.00 453.00 439.00 449.00 457.00 0.00 0.00 0.00 0.00 0.00 0.00 2,656.00 2610 SSI DISABLED EXPANDE 4,690.00 4,558.00 4,352.00 4,034.00 3,906.00 3,733.00 0.00 0.00 0.00 0.00 0.00 0.00 25,273.00 2620 SSI DISABLED EXPANDE 7,464.00 7,627.00 7,830.00 8,020.00 8,167.00 8,316.00 0.00 0.00 0.00 0.00 0.00 0.00 47,424.00 SUBTOTAL: 144,007.00 144,568.00 144,525.00 143,134.00 142,022.00 141,192.00 0.00 0.00 0.00 0.00 0.00 0.00 859,448.00 3300 AHC CARE EXPANDED FO 33.00 33.00 30.00 30.00 31.00 30.00 0.00 0.00 0.00 0.00 0.00 0.00 187.00 3310 AHC CARE EXPANDED FO 26,386.00 24,965.00 23,276.00 22,175.00 21,315.00 20,485.00 0.00 0.00 0.00 0.00 0.00 0.00 138,602.00 3320 AHC CARE EXPANDED FO 23.00 24.00 28.00 28.00 31.00 30.00 0.00 0.00 0.00 0.00 0.00 0.00 164.00 SUBTOTAL: 26,442.00 25,022.00 23,334.00 22,233.00 21,377.00 20,545.00 0.00 0.00 0.00 0.00 0.00 0.00 138,953.00 3600 AHC CARE EXPANDED FO 20.00 21.00 15.00 19.00 22.00 22.00 0.00 0.00 0.00 0.00 0.00 0.00 119.00 3610 AHC CARE EXPANDED FO 83,448.00 80,048.00 76,619.00 73,884.00 71,444.00 68,906.00 0.00 0.00 0.00 0.00 0.00 0.00 454,349.00 3620 AHC CARE EXPANDED FO 2.00 2.00 2.00 1.00 1.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 10.00 33 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 MENTAL HEALTH CAPITATION MEMBER MONTHS - GENERAL 83,470.00 80,071.00 SUBTOTAL: 76,636.00 73,904.00 71,467.00 68,930.00 0.00 0.00 0.00 0.00 0.00 0.00 454,478.00 4510 BC PATIENT FOR FINAN 191.00 198.00 207.00 221.00 213.00 224.00 0.00 0.00 0.00 0.00 0.00 0.00 1,254.00 4610 CC PATIENT FOR FINAN 27.00 27.00 28.00 31.00 30.00 33.00 0.00 0.00 0.00 0.00 0.00 0.00 176.00 SUBTOTAL: 218.00 225.00 235.00 252.00 243.00 257.00 0.00 0.00 0.00 0.00 0.00 0.00 1,430.00 8600 SSI BLIND FREEDOM/WO 1.00 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 6.00 8700 SSI DISABLED FREEDOM 1,200.00 1,194.00 1,193.00 1,207.00 1,185.00 1,181.00 0.00 0.00 0.00 0.00 0.00 0.00 7,160.00 8710 SSI DISABLED FREEDOM 196.00 197.00 188.00 183.00 182.00 182.00 0.00 0.00 0.00 0.00 0.00 0.00 1,128.00 8720 SSI DISABLED FREEDOM 161.00 163.00 165.00 154.00 151.00 158.00 0.00 0.00 0.00 0.00 0.00 0.00 952.00 SUBTOTAL: 1,558.00 1,555.00 1,547.00 1,545.00 1,519.00 1,522.00 0.00 0.00 0.00 0.00 0.00 0.00 9,246.00 TOTAL: 538,864.00 536,123.00 532,771.00 526,964.00 520,824.00 515,159.00 0.00 0.00 0.00 0.00 0.00 0.00 3,170,705.00 34 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 MENTAL HEALTH CAPITATION AMOUNTS - CMDP 1010 TANF NON-MEDICARE 3,344,289.47 3,357,786.19 3,345,253.53 3,448,406.90 3,477,328.40 3,383,815.52 0.00 0.00 0.00 0.00 0.00 0.00 20,356,880.01 2210 SSI DISABLED NON-MED 335,489.45 344,165.92 327,777.03 330,669.15 341,273.70 350,914.21 0.00 0.00 0.00 0.00 0.00 0.00 2,030,289.46 2220 SSI DISABLED WITH QM 964.05 1,928.11 1,928.11 964.05 964.05 964.05 0.00 0.00 0.00 0.00 0.00 0.00 7,712.42 2310 SSI BLIND NON-MEDICA 1,928.10 2,892.15 2,892.15 2,892.15 964.05 1,928.10 0.00 0.00 0.00 0.00 0.00 0.00 13,496.70 4310 SOBRA CHILD NON-MEDI 7,849,295.14 8,068,134.49 8,232,023.06 8,533,770.62 8,608,966.54 8,555,943.78 0.00 0.00 0.00 0.00 0.00 0.00 49,848,133.63 5010 SOBRA PREGNANT WOMAN 27,957.45 23,137.20 21,209.10 25,065.30 26,993.41 23,137.20 0.00 0.00 0.00 0.00 0.00 0.00 147,499.66 11,559,923.66 11,798,044.06 11,931,082.98 12,341,768.17 SUBTOTAL: 12,456,490.15 12,316,702.86 0.00 0.00 0.00 0.00 0.00 0.00 72,404,011.88 1110 TANF EXPANDED FOR FI 964.06 0.00 0.00 0.00 964.06 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,928.12 SUBTOTAL: 964.06 0.00 0.00 0.00 964.06 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,928.12 TOTAL: 11,560,887.72 11,798,044.06 11,931,082.98 12,341,768.17 12,457,454.21 12,316,702.86 0.00 0.00 0.00 0.00 0.00 0.00 72,405,940.00 35 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 MENTAL HEALTH CAPITATION MEMBER MONTHS - CMDP 1010 TANF NON-MEDICARE 3,471.00 3,487.00 3,473.00 3,582.00 3,612.00 3,512.00 0.00 0.00 0.00 0.00 0.00 0.00 21,137.00 2210 SSI DISABLED NON-MED 353.00 364.00 343.00 343.00 354.00 365.00 0.00 0.00 0.00 0.00 0.00 0.00 2,122.00 2220 SSI DISABLED WITH QM 1.00 3.00 3.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 10.00 2310 SSI BLIND NON-MEDICA 2.00 3.00 3.00 3.00 1.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 14.00 4310 SOBRA CHILD NON-MEDI 8,146.00 8,373.00 8,550.00 8,854.00 8,934.00 8,878.00 0.00 0.00 0.00 0.00 0.00 0.00 51,735.00 5010 SOBRA PREGNANT WOMAN 29.00 24.00 22.00 26.00 29.00 24.00 0.00 0.00 0.00 0.00 0.00 0.00 154.00 SUBTOTAL: 12,002.00 12,254.00 12,394.00 12,809.00 12,931.00 12,782.00 0.00 0.00 0.00 0.00 0.00 0.00 75,172.00 1110 TANF EXPANDED FOR FI 2.00 0.00 0.00 0.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4.00 SUBTOTAL: 2.00 0.00 0.00 0.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4.00 TOTAL: 12,004.00 12,254.00 12,394.00 12,809.00 12,933.00 12,782.00 0.00 0.00 0.00 0.00 0.00 0.00 75,176.00 36 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS 1000 TANF WITH MEDICARE 42.41 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 42.41 1005 TANF 14-20 FEMALE WI 0.00 848.20 848.20 848.20 739.22 369.61 0.00 0.00 0.00 0.00 0.00 0.00 3,653.43 1010 TANF NON-MEDICARE 106,420.83 104,342.28 101,852.40 78,995.70 106,910.63 88,213.11 0.00 0.00 0.00 0.00 0.00 0.00 586,734.95 1011 TANF <1 M & F NON-ME 101,781.73 106,654.31 104,561.22 0.00 201,062.06 87,698.85 0.00 0.00 0.00 0.00 0.00 0.00 601,758.17 1012 TANF 01-05 M & F NON 884,329.67 879,221.79 897,669.20 454,889.65 1,166,495.80 745,080.59 0.00 0.00 0.00 0.00 0.00 0.00 5,027,686.70 1013 TANF 06-13 M & F NON 1,109,912.09 1,120,617.18 1,120,720.29 858,830.78 1,282,877.54 1,005,425.46 0.00 0.00 0.00 0.00 0.00 0.00 6,498,383.34 1014 TANF 14-20 MALE NON- 233,594.28 230,860.90 231,353.40 158,669.95 275,037.04 202,712.16 0.00 0.00 0.00 0.00 0.00 0.00 1,332,227.73 1015 TANF 14-20 FEMALE NO 287,949.31 278,346.41 287,430.35 203,681.55 340,212.19 263,188.19 0.00 0.00 0.00 0.00 0.00 0.00 1,660,808.00 1017 TANF 21-44 FEMALE NO 424.10 424.10 424.10 424.10 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,696.40 2200 SSI DISABLED WITH ME 6,785.60 11,505.42 6,785.60 2,544.60 4,598.79 3,326.49 0.00 0.00 0.00 0.00 0.00 0.00 35,546.50 2210 SSI DISABLED NON-MED 4,313,384.69 4,309,511.72 4,297,695.35 3,427,101.49 4,655,227.99 3,752,969.32 0.00 0.00 0.00 0.00 0.00 0.00 24,755,890.56 2220 SSI DISABLED WITH QM 13,387.42 13,174.92 18,468.87 18,632.13 20,810.49 16,854.22 0.00 0.00 0.00 0.00 0.00 0.00 101,328.05 2300 SSI BLIND WITH MEDIC 424.10 424.10 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 848.20 2310 SSI BLIND NON-MEDICA 39,865.40 36,896.70 37,320.80 28,838.80 42,799.66 35,042.33 0.00 0.00 0.00 0.00 0.00 0.00 220,763.69 2320 SSI BLIND WITH QMB 0.00 0.00 424.10 424.10 369.61 369.61 0.00 0.00 0.00 0.00 0.00 0.00 1,587.42 4303 SOBRA CHILD 06-13 M 424.10 424.10 424.10 0.00 424.10 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1,696.40 4304 SOBRA CHILD 14-20 MA 424.10 424.10 424.10 424.10 369.61 369.61 0.00 0.00 0.00 0.00 0.00 0.00 2,435.62 4305 SOBRA CHILD 14-20 FE 0.00 0.00 0.00 0.00 369.61 739.22 0.00 0.00 0.00 0.00 0.00 0.00 1,108.83 4311 SOBRA CHILD <1 M & F 223,165.30 214,399.41 221,699.86 0.00 408,108.51 191,832.42 0.00 0.00 0.00 0.00 0.00 0.00 1,259,205.50 4312 SOBRA CHILD 01-05 M 992,520.78 983,569.97 966,223.37 514,291.93 1,232,642.26 822,448.27 0.00 0.00 0.00 0.00 0.00 0.00 5,511,696.58 4313 SOBRA CHILD 06-13 M 1,121,568.01 1,130,196.87 1,131,608.25 872,260.61 1,225,754.80 982,433.75 0.00 0.00 0.00 0.00 0.00 0.00 6,463,822.29 4314 SOBRA CHILD 14-20 MA 259,478.52 267,224.04 271,478.73 191,636.65 300,274.20 235,503.78 0.00 0.00 0.00 0.00 0.00 0.00 1,525,595.92 4315 SOBRA CHILD 14-20 FE 303,782.82 307,226.25 313,875.05 199,411.82 388,112.25 283,521.62 0.00 0.00 0.00 0.00 0.00 0.00 1,795,929.81 5015 SOBRA PREG 14-20 FEM 16,539.90 16,936.64 14,528.85 10,545.95 16,885.58 13,959.94 0.00 0.00 0.00 0.00 0.00 0.00 89,396.86 10,016,205.16 10,013,229.41 SUBTOTAL: 10,025,816.19 7,022,452.11 11,670,081.94 8,732,058.55 0.00 0.00 0.00 0.00 0.00 0.00 57,479,843.36 1111 TANF EXPANDED <1 M&F 848.20 848.20 424.10 0.00 793.71 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2,914.21 1112 TANF EXPANDED 01-05 9,871.29 9,330.20 11,026.60 3,816.90 15,264.46 6,968.10 0.00 0.00 0.00 0.00 0.00 0.00 56,277.55 1113 TANF EXPANDED 06-13 41,434.57 40,713.60 39,468.66 33,503.90 46,093.64 37,330.61 0.00 0.00 0.00 0.00 0.00 0.00 238,544.98 1114 TANF EXPANDED 14-20 15,267.60 17,853.24 16,539.90 11,026.60 17,068.37 11,827.52 0.00 0.00 0.00 0.00 0.00 0.00 89,583.23 1115 TANF EXPANDED 14-20 24,852.26 21,205.00 24,570.44 19,847.88 28,279.17 21,078.19 0.00 0.00 0.00 0.00 0.00 0.00 139,832.94 2410 SSI AGED EXPANDED NO 424.10 0.00 0.00 0.00 369.61 369.61 0.00 0.00 0.00 0.00 0.00 0.00 1,163.32 2420 SSI AGED EXPANDED WI 0.00 848.20 848.20 0.00 793.71 369.61 0.00 0.00 0.00 0.00 0.00 0.00 2,859.72 2600 SSI DISABLED EXPANDE 0.00 0.00 0.00 0.00 369.61 0.00 0.00 0.00 0.00 0.00 0.00 0.00 369.61 2610 SSI DISABLED EXPANDE 1,696.40 1,696.40 2,120.50 3,392.80 2,641.76 2,217.66 0.00 0.00 0.00 0.00 0.00 0.00 13,765.52 2620 SSI DISABLED EXPANDE 452.37 -1,272.30 0.00 0.00 0.00 369.61 0.00 0.00 0.00 0.00 0.00 0.00 -450.32 SUBTOTAL: 94,846.79 91,222.54 94,998.40 71,588.08 111,674.04 80,530.91 0.00 0.00 0.00 0.00 0.00 0.00 544,860.76 3314 AHC CARE MALE 14-20 17,642.10 15,267.60 15,253.92 14,475.95 16,220.17 14,858.32 0.00 0.00 0.00 0.00 0.00 0.00 93,718.06 37 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 CHILDREN'S REHABILITATIVE SERVICES - CAPITATION AMOUNTS 3315 AHC CARE FEMALE 14-2 14,391.13 16,115.80 14,966.63 11,450.70 15,791.96 12,566.74 0.00 0.00 0.00 0.00 0.00 0.00 85,282.96 32,033.23 31,383.40 SUBTOTAL: 30,220.55 25,926.65 32,012.13 27,425.06 0.00 0.00 0.00 0.00 0.00 0.00 179,001.02 3614 AHC CARE/MI MALE 14- 89,131.69 85,935.89 86,393.27 68,789.01 93,543.81 70,600.80 0.00 0.00 0.00 0.00 0.00 0.00 494,394.47 3615 AHC CARE/MI FEMALE 1 85,555.10 80,620.04 80,291.70 57,423.12 84,009.15 63,168.25 0.00 0.00 0.00 0.00 0.00 0.00 451,067.36 SUBTOTAL: 174,686.79 166,555.93 166,684.97 126,212.13 177,552.96 133,769.05 0.00 0.00 0.00 0.00 0.00 0.00 945,461.83 TOTAL: 10,317,771.97 10,302,391.28 10,317,720.11 7,246,178.97 11,991,321.07 8,973,783.57 0.00 0.00 0.00 0.00 0.00 0.00 59,149,166.97 38 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS 1000 TANF WITH MEDICARE 0.10 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.10 1005 TANF 14-20 FEMALE WI 0.00 2.00 2.00 2.00 2.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 9.00 1010 TANF NON-MEDICARE 250.93 246.02 240.15 186.26 282.39 238.40 0.00 0.00 0.00 0.00 0.00 0.00 1,444.15 1011 TANF <1 M & F NON-ME 239.96 251.41 246.48 0.00 506.14 237.52 0.00 0.00 0.00 0.00 0.00 0.00 1,481.51 1012 TANF 01-05 M & F NON 2,085.12 2,073.10 2,116.56 1,072.59 3,006.86 2,016.27 0.00 0.00 0.00 0.00 0.00 0.00 12,370.50 1013 TANF 06-13 M & F NON 2,617.07 2,642.24 2,642.50 2,025.06 3,367.33 2,720.19 0.00 0.00 0.00 0.00 0.00 0.00 16,014.39 1014 TANF 14-20 MALE NON- 550.79 544.34 545.49 374.13 718.74 549.31 0.00 0.00 0.00 0.00 0.00 0.00 3,282.80 1015 TANF 14-20 FEMALE NO 678.94 656.29 677.71 480.27 889.38 711.47 0.00 0.00 0.00 0.00 0.00 0.00 4,094.06 1017 TANF 21-44 FEMALE NO 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4.00 2200 SSI DISABLED WITH ME 16.00 27.12 16.00 6.00 12.00 9.00 0.00 0.00 0.00 0.00 0.00 0.00 86.12 2210 SSI DISABLED NON-MED 10,170.55 10,161.42 10,133.48 8,080.85 12,262.72 10,143.08 0.00 0.00 0.00 0.00 0.00 0.00 60,952.10 2220 SSI DISABLED WITH QM 31.56 31.06 43.54 43.93 55.41 45.60 0.00 0.00 0.00 0.00 0.00 0.00 251.10 2300 SSI BLIND WITH MEDIC 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 2.00 2310 SSI BLIND NON-MEDICA 94.00 87.00 88.00 68.00 112.46 94.36 0.00 0.00 0.00 0.00 0.00 0.00 543.82 2320 SSI BLIND WITH QMB 0.00 0.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 4.00 4303 SOBRA CHILD 06-13 M 1.00 1.00 1.00 0.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 4.00 4304 SOBRA CHILD 14-20 MA 1.00 1.00 1.00 1.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 6.00 4305 SOBRA CHILD 14-20 FE 0.00 0.00 0.00 0.00 1.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 3.00 4311 SOBRA CHILD <1 M & F 526.18 505.45 522.65 0.00 1,033.08 520.79 0.00 0.00 0.00 0.00 0.00 0.00 3,108.15 4312 SOBRA CHILD 01-05 M 2,340.24 2,319.15 2,278.21 1,212.66 3,183.71 2,222.19 0.00 0.00 0.00 0.00 0.00 0.00 13,556.16 4313 SOBRA CHILD 06-13 M 2,644.57 2,664.87 2,668.19 2,056.73 3,223.66 2,653.70 0.00 0.00 0.00 0.00 0.00 0.00 15,911.72 4314 SOBRA CHILD 14-20 MA 611.80 630.07 640.13 451.86 785.64 636.41 0.00 0.00 0.00 0.00 0.00 0.00 3,755.91 4315 SOBRA CHILD 14-20 FE 716.26 724.40 740.05 470.20 1,008.48 765.12 0.00 0.00 0.00 0.00 0.00 0.00 4,424.51 5015 SOBRA PREG 14-20 FEM 39.00 39.93 34.25 24.86 44.11 37.03 0.00 0.00 0.00 0.00 0.00 0.00 219.18 23,617.07 23,609.87 SUBTOTAL: 23,639.39 16,558.40 30,498.11 23,605.44 0.00 0.00 0.00 0.00 0.00 0.00 141,528.28 1111 TANF EXPANDED <1 M&F 2.00 2.00 1.00 0.00 2.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 7.00 1112 TANF EXPANDED 01-05 23.28 22.00 26.00 9.00 38.64 19.00 0.00 0.00 0.00 0.00 0.00 0.00 137.92 1113 TANF EXPANDED 06-13 97.69 96.00 93.06 79.00 121.60 101.00 0.00 0.00 0.00 0.00 0.00 0.00 588.35 1114 TANF EXPANDED 14-20 36.00 42.09 39.00 26.00 45.00 32.00 0.00 0.00 0.00 0.00 0.00 0.00 220.09 1115 TANF EXPANDED 14-20 58.60 50.00 57.93 46.80 74.04 56.73 0.00 0.00 0.00 0.00 0.00 0.00 344.10 2410 SSI AGED EXPANDED NO 1.00 0.00 0.00 0.00 1.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 3.00 2420 SSI AGED EXPANDED WI 0.00 2.00 2.00 0.00 2.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 7.00 2600 SSI DISABLED EXPANDE 0.00 0.00 0.00 0.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1.00 2610 SSI DISABLED EXPANDE 4.00 4.00 5.00 8.00 7.00 6.00 0.00 0.00 0.00 0.00 0.00 0.00 34.00 2620 SSI DISABLED EXPANDE 1.06 -3.00 0.00 0.00 0.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 -0.94 SUBTOTAL: 223.63 215.09 223.99 168.80 292.28 217.73 0.00 0.00 0.00 0.00 0.00 0.00 1,341.52 3314 AHC CARE MALE 14-20 41.59 36.00 35.97 34.13 43.00 40.20 0.00 0.00 0.00 0.00 0.00 0.00 230.89 39 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 CHILDREN'S REHABILITATIVE SERVICES - CAPITATION MEMBER MONTHS 3315 AHC CARE FEMALE 14-2 33.93 38.00 35.29 27.00 41.73 34.00 0.00 0.00 0.00 0.00 0.00 0.00 209.95 SUBTOTAL: 75.52 74.00 71.26 61.13 84.73 74.20 0.00 0.00 0.00 0.00 0.00 0.00 440.84 3614 AHC CARE/MI MALE 14- 210.16 202.63 203.70 162.20 247.28 191.17 0.00 0.00 0.00 0.00 0.00 0.00 1,217.14 3615 AHC CARE/MI FEMALE 1 201.73 190.09 189.32 135.40 220.63 171.20 0.00 0.00 0.00 0.00 0.00 0.00 1,108.37 SUBTOTAL: 411.89 392.72 393.02 297.60 467.91 362.37 0.00 0.00 0.00 0.00 0.00 0.00 2,325.51 TOTAL: 24,328.11 24,291.68 24,327.66 17,085.93 31,343.03 24,259.74 0.00 0.00 0.00 0.00 0.00 0.00 145,636.15 40 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES 1005 TANF 14-20 FEMALE WI 0.00 0.00 0.00 0.00 0.00 1,120.68 0.00 0.00 0.00 0.00 0.00 0.00 1,120.68 1006 TANF 21-44 MALE WITH -4,207.25 4,179.38 7,189.35 4,227.72 2,464.30 1,808.75 0.00 0.00 0.00 0.00 0.00 0.00 15,662.25 1007 TANF 21-44 FEMALE WI 12,547.23 11,552.94 6,002.57 10,716.53 6,921.52 8,479.37 0.00 0.00 0.00 0.00 0.00 0.00 56,220.16 1008 TANF 45-64 M & F WIT 5,677.06 7,273.96 10,256.01 14,306.58 6,704.65 15,789.52 0.00 0.00 0.00 0.00 0.00 0.00 60,007.78 1009 TANF 65+ M & F WITH 1,630.29 4,749.43 4,131.28 1,490.21 1,910.36 693.34 0.00 0.00 0.00 0.00 0.00 0.00 14,604.91 1011 TANF <1 M & F NON-ME 1,511,673.58 1,815,945.64 1,799,110.97 2,177,763.79 1,419,841.07 1,684,858.47 0.00 0.00 0.00 0.00 0.00 0.00 10,409,193.52 1012 TANF 01-05 M & F NON 2,395,775.38 2,397,801.31 2,616,070.44 3,418,268.74 2,217,349.26 2,555,667.27 0.00 0.00 0.00 0.00 0.00 0.00 15,600,932.40 1013 TANF 06-13 M & F NON 2,078,466.74 2,962,285.56 3,049,564.01 3,704,719.31 2,819,934.48 2,711,129.71 0.00 0.00 0.00 0.00 0.00 0.00 17,326,099.81 1014 TANF 14-20 MALE NON- 459,325.48 903,608.29 797,505.82 666,405.34 679,735.88 594,337.69 0.00 0.00 0.00 0.00 0.00 0.00 4,100,918.50 1015 TANF 14-20 FEMALE NO 1,177,278.44 1,189,532.68 1,591,102.10 1,276,585.82 1,066,945.74 1,318,828.91 0.00 0.00 0.00 0.00 0.00 0.00 7,620,273.69 1016 TANF 21-44 MALE NON- 1,250,233.95 1,283,736.82 1,501,582.28 1,478,813.21 1,224,942.16 1,158,220.62 0.00 0.00 0.00 0.00 0.00 0.00 7,897,529.04 1017 TANF 21-44 FEMALE NO 5,880,267.45 5,656,821.00 7,012,566.00 6,642,663.68 5,586,919.19 5,814,677.48 0.00 0.00 0.00 0.00 0.00 0.00 36,593,914.80 1018 TANF 45-64 M & F NON 1,442,653.11 1,518,234.97 1,797,381.18 1,626,834.67 1,434,672.10 1,412,659.31 0.00 0.00 0.00 0.00 0.00 0.00 9,232,435.34 1019 TANF 65+ M & F NON-M 294.00 588.00 -1,610.00 -1,992.00 996.11 0.00 0.00 0.00 0.00 0.00 0.00 0.00 -1,723.89 1027 TANF 21-44 FEMALE WI 294.00 294.00 -272.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 316.00 1028 TANF 45-64 M & F WIT 914.88 3,847.89 1,977.99 3,328.41 980.30 112.10 0.00 0.00 0.00 0.00 0.00 0.00 11,161.57 1029 TANF 65+ M & F WITH 316.00 54.14 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 370.14 2100 SSI AGED WITH MEDICA 74,750.86 107,261.48 77,448.14 106,581.27 62,418.82 55,621.84 0.00 0.00 0.00 0.00 0.00 0.00 484,082.41 2110 SSI AGED NON-MEDICAR 123,023.03 125,859.45 90,224.52 132,948.17 85,250.49 127,896.96 0.00 0.00 0.00 0.00 0.00 0.00 685,202.62 2120 SSI AGED WITH QMB 214,588.27 512,794.72 365,390.77 452,373.19 345,095.10 358,503.89 0.00 0.00 0.00 0.00 0.00 0.00 2,248,745.94 2200 SSI DISABLED WITH ME 215,389.47 383,865.57 369,513.01 406,941.25 239,198.84 268,889.20 0.00 0.00 0.00 0.00 0.00 0.00 1,883,797.34 2210 SSI DISABLED NON-MED 6,882,846.45 7,698,547.84 8,872,083.71 8,481,669.93 7,434,099.69 7,306,455.19 0.00 0.00 0.00 0.00 0.00 0.00 46,675,702.81 2220 SSI DISABLED WITH QM 777,192.65 1,287,754.52 932,206.66 1,311,634.51 938,473.11 955,603.05 0.00 0.00 0.00 0.00 0.00 0.00 6,202,864.50 2300 SSI BLIND WITH MEDIC 1,139.42 9,268.46 1,916.85 2,716.91 3,100.17 2,837.24 0.00 0.00 0.00 0.00 0.00 0.00 20,979.05 2310 SSI BLIND NON-MEDICA 48,283.89 40,770.54 105,133.46 73,789.39 37,129.50 50,424.40 0.00 0.00 0.00 0.00 0.00 0.00 355,531.18 2320 SSI BLIND WITH QMB 8,146.40 14,170.25 7,230.91 10,132.37 11,095.60 5,757.33 0.00 0.00 0.00 0.00 0.00 0.00 56,532.86 4311 SOBRA CHILD <1 M & F 1,674,900.63 2,272,024.73 1,790,833.46 2,333,622.24 1,554,599.34 1,650,737.57 0.00 0.00 0.00 0.00 0.00 0.00 11,276,717.97 4312 SOBRA CHILD 01-05 M 1,230,627.20 1,221,403.35 1,230,264.32 1,668,118.89 1,124,886.56 1,272,561.40 0.00 0.00 0.00 0.00 0.00 0.00 7,747,861.72 4313 SOBRA CHILD 06-13 M 1,311,261.18 1,472,310.29 1,647,739.86 1,820,656.84 1,402,920.76 1,410,489.16 0.00 0.00 0.00 0.00 0.00 0.00 9,065,378.09 4314 SOBRA CHILD 14-20 MA 483,103.43 761,220.78 749,552.88 679,441.13 595,743.94 580,618.10 0.00 0.00 0.00 0.00 0.00 0.00 3,849,680.26 4315 SOBRA CHILD 14-20 FE 810,959.10 1,029,558.46 981,377.67 772,721.22 1,040,797.80 778,051.57 0.00 0.00 0.00 0.00 0.00 0.00 5,413,465.82 5007 SOBRA PREG 21-44 FEM 51.20 1,293.67 39.24 0.00 433.50 28.45 0.00 0.00 0.00 0.00 0.00 0.00 1,846.06 5015 SOBRA PREG 14-20 FEM 591,569.93 576,664.08 778,735.36 526,742.07 470,643.06 515,109.94 0.00 0.00 0.00 0.00 0.00 0.00 3,459,464.44 5017 SOBRA PREG 21-44 FEM 1,299,563.20 1,426,317.04 1,622,849.27 1,613,187.48 1,380,157.64 1,356,220.52 0.00 0.00 0.00 0.00 0.00 0.00 8,698,295.15 5018 SOBRA PREG 45-64 FEM 1,396.35 3,399.53 9,957.18 11,890.62 9,433.93 4,778.30 0.00 0.00 0.00 0.00 0.00 0.00 40,855.91 5510 SOBRA FPS FEMALE WIT 19,348.00 13,684.00 13,646.00 19,498.00 23,263.95 25,143.80 0.00 0.00 0.00 0.00 0.00 0.00 114,583.75 31,981,281.00 36,718,674.77 39,838,701.27 41,448,797.49 SUBTOTAL: 33,229,058.92 34,004,111.13 0.00 0.00 0.00 0.00 0.00 0.00 217,220,624.58 3100 TRANSPLANT OPTION 1 51.73 1.35 5,511.43 324.91 17.31 0.00 0.00 0.00 0.00 0.00 0.00 0.00 5,906.73 41 RATE CODE DESCRIPTION JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH APRIL MAY JUNE TOTAL For the Period Ending December 31, 2012 ACUTE FEE FOR SERVICE - EXCLUDING EMERGENCY SERVICES SUBTOTAL: 51.73 1.35 5,511.43 324.91 17.31 0.00 0.00 0.00 0.00 0.00 0.00 0.00 5,906.73 1106 TANF EXPANDED 21-44 8,168.09 13,919.24 12,397.68 24,703.27 13,404.01 13,401.69 0.00 0.00 0.00 0.00 0.00 0.00 85,993.98 1107 TANF EXPANDED 21-44 12,944.26 29,142.92 22,874.19 51,393.86 28,864.23 26,626.99 0.00 0.00 0.00 0.00 0.00 0.00 171,846.45 1108 TANF EXPANDED 45-64 79,430.84 112,508.02 67,155.39 97,284.87 84,695.33 61,994.01 0.00 0.00 0.00 0.00 0.00 0.00 503,068.46 1109 TANF EXPANDED 65+ M& 9,337.40 15,637.28 11,969.29 15,452.22 7,354.10 8,582.63 0.00 0.00 0.00 0.00 0.00 0.00 68,332.92 1111 TANF EXPANDED <1 M&F 1,371.30 306.43 982.47 837.71 1,596.44 2,244.55 0.00 0.00 0.00 0.00 0.00 0.00 7,338.90 1112 TANF EXPANDED 01-05 18,067.16 11,475.47 15,676.69 20,458.18 16,692.66 11,824.33 0.00 0.00 0.00 0.00 0.00 0.00 94,194.49 1113 TANF EXPANDED 06-13 31,399.41 43,055.73 45,723.40 64,433.49 42,918.00 51,317.91 0.00 0.00 0.00 0.00 0.00 0.00 278,847.94 1114 TANF EXPANDED 14-20 14,812.09 23,863.24 32,266.34 26,283.42 54,733.28 28,949.45 0.00 0.00 0.00 0.00 0.00 0.00 180,907.82 1115 TANF EXPANDED 14-20 71,061.54 66,999.22 75,376.95 50,006.19 47,803.92 64,390.81 0.00 0.00 0.00 0.00 0.00 0.00 375,638.63 1116 TANF EXPANDED 21-44 586,805.37 678,241.40 624,339.62 735,783.15 583,084.59 612,135.01 0.00 0.00 0.00 0.00 0.00 0.00 3,820,389.14 1117 TANF EXPANDED 21-44 1,573,375.76 1,545,793.44 1,775,465.91 1,620,664.05 1,332,327.49 1,446,518.79 0.00 0.00 0.00 0.00 0.00 0.00 9,294,145.44 1118 TANF EXPANDED 45-64 935,675.86 1,033,489.60 979,453.39 936,784.92 779,388.93 814,432.99 0.00 0.00 0.00 0.00 0.00 0.00 5,479,225.69 1119 TANF EXPANDED 65+ M& 0.00 1,264.00 346.41 -1,168.12 632.00 810.40 0.00 0.00 0.00 0.00 0.00 0.00 1,884.69 1126 TANF EXPANDED 21-44 1,593.52 1,878.53 865.53 814.08 0.00 1,786.49 0.00 0.00 0.00 0.00 0.00 0.00 6,938.15 1127 TANF EXPANDED 21-44 72.39 0.00 0.00 37.79 0.00 4.26 0.00 0.00 0.00 0.00 0.00 0.00 114.44 1128 TANF EXPANDED 45-64 1,369.17 4,483.75 3,031.91 6,987.95 5,506.33 3,907.72 0.00 0.00 0.00 0.00 0.00 0.00 25,286.83 1129 TANF EXPANDED 65+ M& 376.93 544.65 1,613.11 800.52 195.55 441.93 0.00 0.00 0.00 0.00 0.00 0.00 3,972.69 2400 SSI AGED EXPANDED WI 14,173.56 8,537.52 20,900.81 19,515.60 14,482.33 11,823.45 0.00 0.00 0.00 0.00 0.00 0.00 89,433.27 2410 SSI AGED EXPANDED NO 59,018.16 94,645.31 93,985.33 76,934.47 74,296.89 107,747.04 0.00 0.00 0.00 0.00 0.00 0.00 506,627.20 2420 SSI AGED EXPANDED WI 219,999.03 383,968.92 264,707.18 350,613.81 280,610.70 312

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